Quality of Care in Hospital and Postdischarge Mortality

For many older patients, hospitalization for an acute medical illness is a critical moment in their lives as their hope for improved health confronts the hazards of hospitalization. Elements of hospitalizationFprolonged immobility, undernutrition, and a ‘‘hostile’’ environmentFincrease the risk of functional decline and loss of independence in performance of daily activities, resulting in placement in a nursing facility or subsequent mortality. Although geriatric models of care improve the quality of patient care during hospitalization, they have not been widely implemented in the United States, and the effect of these interventions on postdischarge mortality remains to be demonstrated. With healthcare reform and changes in the Medicare program at center stage, empirical data are needed to inform future priorities in the process of measuring quality of care of hospitalized older patients. A particular challenge to providers and payers is to define and document meaningful metrics of quality of care of hospitalized older patients. The quest for evidence that quality indicators (QIs) are associated with better health outcomes has been elusive. Different methods are used to document or promote quality of care by hospitals and physicians, including measurement of adherence to clinical practice guidelines and pay-for-performance measures. Clinical practice guidelines, with endorsement from medical societies and organizations including the Centers for Medicare and Medicaid Services (CMS), define standards of care. These guidelines often target disease-specific conditions that are high risk, common, and associated with unplanned hospital readmission or death. The guidelines are commonly transformed into QIs that can be measured through administrative review of hospital records and databases. The Hospital Quality Alliance, a public–private collaboration, generates data about performance measures from hospitals across the United States that evaluate processes of care for patients with three medical conditions (acute myocardial infarction (AMI), heart failure, and pneumonia) and surgical site infections. The quality performance data are posted on the CMS website Hospital Compare (http://www.HospitalCompare.hhs.gov). The Joint Commission on the Accreditation of Healthcare Organizations also uses these reports in the process of hospital accreditation. A study of hospital care for the three medical conditions showed that hospital performance measures predicted small differences in subsequent mortality, underscoring the need to tightly link performance measures with patient outcomes. Another approach to improving processes of hospital care that presumably link to optimal outcomes is to offer financial incentives to physicians and hospitals that adhere to quality standards. Pay for performance has been studied in the CMS Hospital Quality Incentive Demonstration that examines the process of care for AMI, heart failure, pneumonia, and coronary artery bypass grafting. A recent analysis found no evidence that the demonstration had a significant effect on 30-day mortality for these conditions. Although older patients often have one of these common conditions, QIs often do not take into account the effects of frailty, multiple comorbid diseases, and the ‘‘competing priorities’’ that complicate the quality of medical care of elderly patients. In addition, the focus on disease-specific clinical practice guidelines as the basis for defining quality of care in pay-for-performance measures might create incentives for physicians and hospitals to ignore the complexity of comorbid chronic diseases. In this context, the Assessing Care of Vulnerable Elders (ACOVE) project has taken important strides in defining and measuring QIs. A Vulnerable Elders Survey-13 (VES13) score (range 0–10) of 3 or higher defines vulnerable as a patient at risk of functional decline or death, with higher scores being associated with greater rates of mortality. The original measures were revised and expanded with ACOVE-3 and include QIs for hospitalization and surgery in vulnerable elders. In this issue of the Journal, Arora and colleagues provide compelling evidence that adherence to 17 ACOVE measures is associated with lower likelihood of death 1 year after hospital discharge. Subjects who were vulnerable and survived to discharge were enrolled from an ongoing study of patients aged 65 and older admitted to the general medicine inpatient service at the University of Chicago Medical Center. Patients discharged to hospice or comfort care and those with hospital stay of 1 day or less, intensive care transfer, or readmission within 30 days were excluded. Data were collected about the patient’s current functional limitations in each of six activities of daily living (ADLs) at the time of admission. Of the 17 ACOVE QIs, six were abstracted from patient charts; an additional 11 conditionspecific QIs were abstracted when there was documentation of the condition. The Social Security Death Index confirmed dates of death of patients. To account for effects of illness and physical function that affect outcomes, the authors used seven different markers of patient illness. The number of QIs for which a patient was eligible was used as a proxy measure of the patient’s relative severity of illness. A composite quality score was derived for each patient based on DOI: 10.1111/j.1532-5415.2010. 03028.x