Systems approaches to improve quality, performance, and efficiency in the care of older adults.

In the early years of the 21st century, the US health care system is in a state of both feast and famine. New scientific breakthroughs and advances in technology have cured diseases and extended lives beyond what was imaginable even a decade ago. Yet despite these riches, the health care system is fundamentally broken. It fails on three measures of care, especially in the treatment of older persons. … data from the Centers for Medicare and Medicaid Services demonstrate that across the states, as more money is spent, the quality of care is worse.6 The first measure is cost. In 2004, the cost of health care in the United States grew at a rate of 7.7%, compared to the overall consumer price index of 4.4%. 1 In fact, many US economists have accepted—but do not like—that health care spending will rise at a rate of 2% to 3% higher than the general economy. The second measure indicating failure is patient satisfaction. When elderly patients were asked in a recent survey about their physicians, they reported that physicians listen carefully 65% of the time, explain things clearly 59% of the time, and spend enough time with them only 54% of the time.2 Of course, patient satisfaction will never be 100%, but it should be 80% to 90%. The third measure on which health care fails is quality. In a study published in 2003, performance on quality indicators for 30 conditions and preventive care was measured. Only 55% of recommended care was provided—and there was tremendous variation in the quality of care provided. For cataracts, 80% of recommended care was provided, whereas for hip fractures, it was only 23%. 3 The Assessing Care of the Vulnerable Elderly (ACOVE) study began by developing an instrument to identify vulnerable elders—older people at higher risk of dying or having functional decline within two years.4 The ACOVE team then created quality indicators, on the basis of literature review and evaluation by an expert panel, for 22 conditions (eg, coronary artery disease, dementia, falls, urinary incontinence). Finally, they performed a medical records review and structured interviews for each condition for patients enrolled in two health plans—on the East and West Coasts. The overall results were virtually identical to those of the first study. Only 55% of quality indicators were met.5 However, they also found that the care for geriatric conditions such as falls, urinary incontinence, and dementia was much worse than for general conditions such as atrial fibrillation and stroke. For geriatric conditions, only 31% of recommended care was provided, again with high variability in quality of care; for example, 82% of recommended stroke care was delivered, but only 9% of end-of-life quality indicators were met. Physicians say they could provide better care if there was more money and more time. However, data from the Centers for Medicare and Medicaid Services demonstrate that across the states, as more money is spent, the quality of care is worse.6 To address these failings, it is important to review the current state of health care to identify barriers to good health care and to review individual and systems efforts to improve health care.