Can hospitalization-associated disability be prevented?

EACH YEAR, NEARLY 1 MILLION OLDER ADULTS ARE HOSpitalized in the United States for treatment of an acute illness. Although many hospitalizations are necessary and lead to improvement, iatrogenic complications are common. All too frequently, older patients develop infections, pressure ulcers, delirium, adverse effects from treatment, and falls resulting in injury, among other complications. According to a report by the Office of the Inspector General, 7.4% of Medicare beneficiaries who were hospitalized in 2008 experienced a preventable adverse event. To improve the quality and safety of hospital care, Congress has enacted several broad programs that mandate reporting of quality, safety, patient experience, and adverse events and that provide financial incentives to improve performance. An insidious and underappreciated complication associated with hospitalization of older adults for acute illness is the loss of independence that comes from the inability to perform self-care functions. As noted by Covinsky et al in this issue of JAMA, at least 30% of patients aged 70 years and older and hospitalized with a medical illness are discharged with a new disability that was not present before the onset of illness. Hospitalization-associated disability involves the new loss of ability, by discharge, to perform at least 1 of the basic activities of daily living (ADLs), such as bathing or showering, dressing, transferring out of a bed or chair, eating, and walking without assistance. The loss of independence has profound implications for these patients often, portending long-term care in a nursing home, repeat hospitalization, and even death. Despite the importance of hospitalization-associated disability, it is virtually ignored by health care professionals and policy makers. One reason for this lack of awareness is that healthrelated quality of life and sustainability of independence are not measured as outcomes of care. The Centers for Medicare & Medicaid Services (CMS) publishes hospital quality measures on its Hospital Compare Web site, but neither the current nor proposed hospital quality metrics measure healthrelated quality of life. Starting in October 2012, Medicare will reward hospitals that provide this sort of high-quality care for their patients and withhold a portion of payments to those hospitals that do not through the hospital ValueBased Purchasing (VBP) program. Inpatient, prospective payment hospitals will contribute 1% of their Medicare base operating diagnosis related group payments to a VBP pool of dollars. Hospitals will be eligible to receive a VBP payment amount based on a composite quality score. Initially, that score will comprise a hospital’s performance in process measures and the patient’s experience in the hospital. The amount of money at risk increases in succeeding years, and the list of measures will expand to include adverse events, efficiency, and mortality, but no measures of physical function or other aspects of health-related quality of life. Thus, the VBP program will not fully measure and reward value from the patient’s standpoint. Most hospitals will focus time and energy only on improving those measures that are publically reported and that determine reimbursement. Physical function and other dimensions of quality of life should be measured over the course of illness. Simple, valid, and reliable instruments that measure functional status should be incorporated into the care process for older patients and also should be used at regular intervals and at transitions of care. The value of measurement will increase as hospitals and physicians implement electronic health records, facilitating assessment of health-related quality of life aggregated across populations of older patients to better understand trajectories and causes of physical disability. Measurement alone is not sufficient to address the problem, but measurement would facilitate assessing interventions for effectiveness. What can and should be done to avert the onset of new disability associated with an acute illness requiring hospitalization? The answer to this question remains unclear and additional study is needed. Although patients at high risk of disability can be identified prospectively, which patients have reversible and/or preventable loss of function can-