PURPOSE: Despite mounting evidence that beta-adrenergic antagonists (beta-blockers) are beneficial immediately following acute myocardial infarction (AMI), a median of only 64% of Medicare beneficiaries nationwide receive beta-blocker within 24 hours of AMI. Measuring use of beta-blockers in AMI usually requires expensive chart reviews. Using a comprehensive electronic medical records system instead of chart review, we sought to measure use of betablockers in AMI as well as differences in charges between those who received beta-blocker and those who did not. METHODS: We examined data from all 15,610 Medicare-covered hospitalizations during 1995 ± 99 for 7,251 patients in an urban academic medical center, evaluating for International Classification of Diseases codes for AMI. Restricting study to patients 65 years of age or older, we collated and merged into this all available prescription drug data pertaining to these patients, separating inpatient from outpatient drugs based on date. We then calculated rates of betablocker use in AMI and differences in estimates of total hospital charges and length of stay depending on whether beta-blocker were prescribed. RESULTS: Of 9,191 hospitalizations among 4,490 older adults, 385 (4%) contained a diagnostic code for AMI. Beta-blockers were prescribed in 252 (65%) of the encounters, and 85% of prescriptions occurred on the date of admission or one day later. Overall, beta-blocker prescriptions occurred on one of these days in 55% of hospitalizations for AMI. Metoprolol was the beta-blocker prescribed most often (77% of beta-blocker use in AMI). Of those receiving any beta-blocker, 3% had a diagnostic code for obstructive lung disease, compared to 5% among those not receiving beta-blockers (p = 0.37). Those receiving beta-blockers had mean length of stay 1.5 days longer (p < 0.05) but mean charges not significantly different from those not receiving beta-blockers. CONCLUSION: A comprehensive, electronic medical records system can be used instead of resource-intensive chart review to measure use of beta-blockers after AMI. Uncertainty about the precise relationship between the two methods should prompt, as a next investigative step, a more direct comparison of chart review to the use of electronic records to measure indicators of quality of healthcare. shown that these agents are underutilized in practice. Contributing to this finding is the perception that other agents may work better or have fewer side effects. Under the assumption that a medication class switch represents a physician's belief that the medication was of little benefit, or was not well-tolerated by the patient, this study compares the degree to which each of the major classes of antihypertensive medications is discontinued in favor of another class of antihypertensive. METHODS: We examined pharmacy data from a population of Medicare patients enrolled in a managed care organization (MCO) between December 1996 and October 2000. An overall interval of antihypertensive medication usage was determined for each patient. The subset of this time interval in which the patient received a beta blocker (BB), calcium channel blocker (CCB), ACE inhibitor (ACEI), or diuretic was determined. A therapy class switch was defined as prescribing a new class of antihypertensive medication more than one month after the end of the original antihypertensive class interval ended. In this manner, the addition of a second antihypertensive would not be considered a class switch, unless the first medication was stopped permanently, and the second medicine continued for more than a month. RESULTS: Of the 9798 patients who filled at least 3 antihypertensive prescriptions over at least 90 days, 4260 received a BB, 4225 received a CCB, 4533 received an ACEI and 3480 received a diuretic (sum exceeds total since patients could have been on more than one class). Kaplan Meyer survival analysis indicates that after 1000 days, a higher percentage of patients continue to take BB (68.5%) than ACEI (63.8%), CCB (61.8%) or diuretics (53.4%). The length of time until 25% of patients had switched their medication class was longest for the group taking BB (760 days), then ACEI (589 days), CCB (568 days) and diuretics (387 days). This trend favoring BB is also observed when limiting the analysis to classes of antihypertensives that were initiated in the observation period. CONCLUSION: The results of the study suggest that, contrary to common perceptions, among a Medicare population, beta blockers are not more commonly discontinued than the more modern, and expensive antihypertensive agents. While the clinical factors that influence a physician's decision to start a particular medication class are not known, this potential bias is mitigated by the common tenets of good clinical practice. These tenets dictate that when choosing to prescribe any class of drug, the physician believes it would be safe, effective and well tolerated. The study results suggest that, regardless of the initial indications for choosing a particular therapeutic class of antihypertensive, or the reason for eventually changing the class (non-compliance, patient complaints, ineffectiveness, expense, etc.), BB seem less likely than ACEI and CCBs to be switched, while diuretics are more likely than the other classes to be discontinued. PURPOSE: Attention to issues of autonomy, surrogates and treatment preferences are important for vulnerable elders, who are at risk of decisional incapacity and death. We investigated these elements of end-of-life care among a cohort of vulnerable elders. METHODS: The Assessing Care of Vulnerable Elders project developed and tested quality indicators (QIs) for community-based personsÊ65 years at increased risk of death or functional decline. Based on a systematic literature review, an expert panel rated 14 QIs related to documentation about surrogates and preferences, and translation of preferences into care as valid process measures for end-of-life care. We measured these QIs by reviewing 13 months of inpatient and outpatient charts of patients in 2 managed health plans. RESULTS: Of 3206 seniors randomly selected from the plans, 2,278 (71%) were interviewed and 475 were identified as``vulnerable''. Of 400 (84%) who consented to study participation and had abstractable medical records, 376 were eligible for at least one QI. Fourteen elders (4%) had any documentation (formal or informal) about surrogate decision makers in their outpatient charts. Charts for 103 hospitalizations yielded 8 advance directives, 23 noted a surrogate or an attempt to find one, and 72 (70%) contained no documentation. When hospitalized with altered mental status, 5 of 20 elders had any documentation about a surrogate within the first 3 hospital days and 1 of 6 elders admitted to an ICU had any documentation about preferences within 3 days. Seventy percent of orders to limit care in the hospital considered patient participation in decision-making and 2 of 2 ventilated patients had documentation about preferences. CONCLUSION: Despite much recent attention to end-of-life care, surrogates and preferences are not elicited prospectively from vulnerable elders. Improvement in the quality of end-of-life care is needed, particularly for persons at risk of life-threatening events. PURPOSE: Measurement of quality of care (QOC) for mainstream medical conditions has received much attention, but no method exists to measure QOC for geriatric conditions. We developed a system to comprehensively measure QOC provided to vulnerable elders and compared QOC for geriatric and medical conditions. METHODS: Based on structured literature reviews, content experts developed 239 quality indicators (QIs) for the process of medical care provided to``vulnerable elders'', communitybased persons > 64 years old at increased risk of death or functional decline. These QIs assessed care for 22 conditions. We applied these QIs to a community sample of vulnerable elders by abstracting their outpatient and inpatient charts, comparing QOC provided for medical conditions (depression, diabetes, heart failure, hypertension, coronary disease, osteoarthritis, osteoporosis, pneumonia and stroke) to geriatric conditions (delirium, dementia, falls, geriatric assessment, incontinence, malnutrition and pressure ulcers) RESULTS: Of 3206 seniors randomly selected from two managed senior health plans, 2,278 (71%) were interviewed and 475 were identified as``vulnerable''. Of these, 400 (84%) consented to participate and had abstractable charts. For medical conditions, 52% of 1897 QIs were satisfied (e.g. diabetes 58%, heart failure 72%). This was significantly better (p < 0.01) than the 37% of 2036 QIs satisfied for geriatric conditions. Compliance rates for geriatric conditions included falls 26%, dementia 35% and incontinence 29%. CONCLUSION: QOC for geriatric conditions falls far below that of QOC for medical conditions. Quality assessment and assurance systems should incorporate QIs measuring geriatric syndrome care. Care for geriatric conditions ± common among vulnerable elders and associated with functional decline and mortality ± must be improved. PURPOSE: Continuity and coordination (CC) of care are core elements of general internal medicine. This is particularly important for``vulnerable elders'' who may be at high risk of adverse events due to poor CC. Yet there is no method of measuring CC in medical care. We developed and tested a system to measure CC of care among a cohort of vulnerable elders. METHODS: The Assessing Care of Vulnerable Elders project developed and tested quality indicators (QIs) for community-based persons > 64 years at increased risk of death or functional decline. Based on a systematic literature review, an expert panel rated 13 QIs as valid process measures of care CC. Six of these could be measured by abstracting information from medical records. QIs evaluated medication, test and information continuity, within and between providers, across the inpatient and outpatient settings.