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6
Quality of Care
National data systems have been a largely underdeveloped source
of information for measuring quality of care among the elderly. There
are compelling reasons for identifying needs for this type of informa-
tion and the extent to which such systems could meet them. The
Office of Technology Assessment (1985a:77) points out that "Medi-
care's prospective payment system (PPS) has intensified concern
with the complex relationship between cost and quality of medical
care" and that "assessing PPS impacts on quality of care is critical."
Among the reasons given is that, if PPS succeeds as a cost contain-
ment strategy, "its effect on the quality of care will be a deciding
factor in the program's continual survival." Another report (Insti-
tute of Medicine, 1986) focuses on the importance of information
systems for assessing and improving the quality of care of nursing
home residents and recommends (p. 43) that the secretary of the
Department of Health and Human Services "undertake a study to
design a system of acquiring and using resident assessment data."
These reports reflect the emergence of quality of care as a matter
of central interest for policies directed at controlling costs or improv-
ing services for specific subgroups of the elderly. The larger context
consists of an agenda of policies concerned with the application of
prospective payment systems to sectors other than hospital care,
modifications in Medicare and Medicaid benefits, and availability of
staff, facilities, anct alternative sources of care, particularly for the
Tong-term care patient.
Policies that have been adopted, or are being contemplated, may
126
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QUALITY OF CARE
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.
127
have both short-term and long-term effects on quality of care, but the
character of these effects is not clear. The potential for differential
effects exists because of the diversity of health care systems; the
increasing competition among providers; and the heterogeneity of the
elderly population. The elderly vary in their health and mental health
care needs, social and economic status, and living arrangements-
circumstances subject to rapid change as age advances (Shanas and
Maddox, 1985~. The utility of information on quality of care for
national policy purposes is directly related to the ability to examine
relationships involving these variables.
Selected policy questions relating to the quality of care, listed
in order from issues that require research or evaluations to questions
that depend on or are related to measurement of quality of care
include:
Should quality assurance mechanisms for health care services
of the elderly be strengthened because of the adverse effects
of cost containment?
Should Professional Review Organizations (PROs) under
Medicare be strengthened to ensure quality of care for Medi-
care beneficiaries?
. To what extent should government and private insurance
programs regulate quality of care under their reimbursement
mechanisms?
How has the change in Medicare's payment system to DRGs
affected the quality of care for elderly patients?
Has the emergence of competitive health maintenance or-
ganizations (HMOs) provided economic incentives for their
elderly enrollees or affected the quality of care provided to
them? Who should be responsible for monitoring quality of
care in HMOs?
How can we develop, refine, and implement improved and
standardized measurements of quality of care for older peo-
ple? Who should be responsible?
The discussion that follows presents the framework within which
quality of care is most often examined, identifies several measures
of quality of care suitable for national data systems, and considers
steps needed to ensure availability of such measures.
A FRAMEWORK FOR QUALITY OF CARE ASSESSMENT
It is now possible to talk about a generation of effort to progress
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
from broad definitions of quality of care to the identification of crite-
ria that can be applied to measure quality. Although specific details
of quality of care assessment have varied, the framework that is most
widely accepted consists of three components-structure, process,
and outcome (Donabedian, 1980~. Pr~rnary emphasis in explicating
these concepts has been directed at the diagnosis and management of
illness and is focused on transactions between providers and patients
to achieve an appropriate balance of health benefits and risks.
This is clearly an essential aspect of quality of care and is ex-
emplified by approaches taken by Professional Review Organizations
in developing programs for quality assurance of inpatient care for
Medicare beneficiaries (Mohr, 1985~. Other aspects of quality of care
that require greater prominence and that are readily accommodated
within the categories, structure, process, and outcome, are oriented
toward prevention and a consideration of how a system of care is
functioning, not only with respect to those who appear for care at
the time they do so, but also in terms of the need that exists in a
community or general population. Quality is affected by both the
technical performance of providers and the extent to which a system
reaches those in need, for example, hypertensives under treatment
may have high levels of control, but on a population basis there may
be a high prevalence of uncontrolled hypertension.
The usual formulation of what is included under each category
is given below, expanded to cover some of these considerations.
Structure refers to relatively stable parts of the health care sys-
tem, such as numbers, types, and qualifications of professional per-
sonnel, physical facilities, and medical technologies; it also includes
organization ant] distribution of different types of services, proximity
to the population being served, and other factors affecting access to
care.
Process refers to what is done to and for the patient or a de-
fined population and how it is done; this includes the application
of preventive, diagnostic, and therapeutic procedures, nursing and
home care, counseling, referral practices, and coordination of care,
follow-up, and monitoring procedures.
Outcome refers to changes in health status or maintenance of
desirable levels of health influenced by health services; this includes
one or more dimensions of physical and psychosocial functioning, dis-
ability, prevention of disease or complication of disease, satisfaction
with health care, and mortality.
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QUALITY OF CARE
129
A comprehensive assessment of quality of care would be con-
cerned with all three components and their interrelationship, with
the ultimate measure of quality determined by the outcome of care
(Kessner et al., 1973~. In practice, there are often severe constraints
in linking particular structural factors and processes of care to spe-
cific measures of health status. Standards for many elements of
structure are based on professional judgments and are used for such
purposes as accreditation, licensing, Medicare certifications, and es-
tablishing qualifications for staff in, for example, hospitals, group
practices, and nursing homes. However, standards do not always
represent a consensus; they are subject to change as new knowledge
is acquired and new technology developed, and different structural
patterns may achieve similar levels of quality. Furthermore, the fact
that standards are met does not provide assurance that a favorable
effect on health status will follow. In short, structural factors such
as the availability of highly qualified primary care providers, special-
ists and support services, or regionalized emergency medical service
systems may increase the probability of receiving high-quality care,
but they are not sufficient conditions for determining quality.
Process of care measures provide more generally accepted indi-
cators of quality of care, reflecting as they do what care is delivered
and how. The measures are derived mainly from professional norms
of practice or research in which some link to outcome is unplicitly
or explicitly expected, whether this is improved functioning, delay
in dependency, or relief from pain or depression. The degree of cer-
tainty about a link may be weak in some cases because of lack of
information about the natural history of disease, the relative effec-
tiveness of alternative treatment modalities, or the role of behavioral
and biological characteristics of patients in determining the course
of illness. The selection of process measures for assessing quality
of care seeks to minimize these limitations. Measures are available
or being developed that range from adherence to algorithms for the
treatment of specific conditions (Greenfield et al., 1981) to commu-
nication and counseling (Inui and Carter, 1985), detection of need
for health services (Aday and Andersen, 1975; Shapiro et al., 1985),
matching need with appropriate sources of care in acute episodes of
illness and in Tong-term care, for which coordination of services is
important (Mathematica Policy Research, Inc., 1986~.
The pessimism that long pervaded the outlook for having out-
come measures to assess quality of care has been replaced by a more
optimistic view. Although there are many uncertainties about how
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
health status is influenced by personal and social factors, knowledge
has cumulated regarding the effectiveness of specific health care in-
terventions. Advances have been made in the development, testing,
and application of health status measures to supplement indices of
mortality that are useful in examining both technical and health care
system effects on the health of a population (Bergner, 1985; Brook
and Lohr, 1985~. This holds true for Al age groups, but it is par-
ticularly relevant for the elderly, whose neecis for health services are
high and large proportions of whom could be affected positively or
negatively.
We specify outcome measures under the three functional goals
of health care below:
Caring involves reassurance and relief from anxiety, satisfaction,
and communication between provider and patient, which may affect
whether regimens prescribed are followed and response to symptoms
and care-seeking are appropriate.
Curing an] maintenance involve a reduction in symptoms and
dependency, avoidance of complications and iatrogenic effects of
treatment and reversing the effects when they occur, improvement
or stabilization in functional capacity, and reduction in avoidable
mortality. Many specific conditions are candidates for observation,
such as hypertension, angina, hip fractures, major depression, glau-
coma, cataracts, respiratory diseases, and hearing, visual, and dental
defects.
Functional status measures detailed in Chapter 3 represent a
spectrum of physical, emotional, and social indicators of health sta-
tus. They reflect the results of an interaction between population
and environmental conditions and processes of care determined by
how the delivering system and individual practitioners function. This
type of interaction affects aspects of health care such as matching
need with demand as affected by availability and.access to care,
timeliness of medical intervention, planning of long-term care and
post-hospital care, coordination of multiple sources of care, and con-
tinuity of care.
Prevention measures are designed to prevent, delay, or reverse
the progression of disease, and reduce functional lirrutation, handi-
cap, or dependency due to health conditions. A preventive measure
may be interpreted as a surrogate or intermediate outcome measure
when its effect on a health condition or health status has been estab-
lished, when it reaches the population that is at risk and can benefit
from it, and when there is appropriate follow-up.
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QUALITY OF CARE
131
The potential and limitations of what can be gained from specific
measures are discussed in Chapter 5. A full treatment of prevention
would consider degrees of certainty about efficacy, cost-effectiveness
of particular prevention measures, state of readiness among providers
to apply them, and method and frequency of the interventions. How-
ever, the application of prevention procedures that are generally
viewed as desirable would serve as an indicator of quality of care.
These inclucle examination and follow-up of asymptomatic individ-
uals for such conditions as hypertension, visual defects, impaired
hearing, hypercholesteremia and counseling on smoking cessation,
exercise, rest, diet, and rehabilitation aimed at restoring function
consistent with the maximum achievable level.
THE ROLE OF NATIONAL INFO1IMATION SYSTEMS
National data systems have the capacity to produce information
needed to derive quality of care measures to determine how quality
varies within the population and how it may be influenced by sources
of care and policies that affect services received. Many of the specific
items required are included in surveys that are already operational
or about to start; others are dependent on the extension of existing
items or the introduction of new ones.
Additional efforts will be needed to develop and test new mea-
sures of outcome and processes of care, as well as methods for making
reliable and valid observations on the elderly who are well and those
who are infirm or cognitively impaired. In this regard, particular
attention needs to be given to methodology and research pertaining
to cognitive aspects of survey design, i.e., aspects of survey research
interviews pertaining to cognitive processes such as understanding
language, remembering and forgetting, perception, judgment, and
inferring causes. One direction for such activity is the specification
of better questions as well as better ways of expressing questions with
respect to cognitive considerations (Fienberg et al., 1985; I,essler and
Sirken, 1985~. Another is the use of flagging procedures by interview-
ers to indicate their degree of belief in the correctness of reported
responses. Such information could then play a helpful role in the
evaluation of the sensitivity of estimates to possibly varying levels of
data accuracy. Methodology for expressing the results of such efforts
in terms of bias or accuracy also needs better development.
A significant expansion in the measurement of quality of care
can be achieved before results of new research are available through
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
the use of currently available or readily adaptable measures, linkage
of multiple data sets, and longitudinal information systems. Imple-
mentation of the recommendations in earlier sections of this report
on health status and health promotion, as well as those in later sec-
tions on utilization and Tong-term care, would achieve this purpose.
The additional requirement is a coherent strategy for placing the
measures in a quality of care framework.
In developing this strategy, it is important to bear in mind that
national information systems should have the capacity to measure
quality directly. They should also provide broad indicators of quality
of care that can signal that other sources of information are needed
(Rutstein et al., 1976~. For example, an alert was signaled in 1986
when the Health Care Financing Administration (HCFA) released
hospital mortality rates derived from the Medicare hospital bills.
The result was to focus attention on how patients are managed in
the hospital. Another effect should be to intensify the development
of severity of illness measures that are feasible for inclusion in data
systems on hospital discharges (Horn and Horn, 1986~.
Indicators of quality of care would become more readily available
with the adoption of the Long-Term Health Care Minimum Data Set
(U.S. Department of Health and Human Services, 1980b), and this
would provide a basis for probing more fully into processes of care
in institutional and noninstitutional settings. Also relevant for the
development of quality of care measures are the recommendations of
the Institute of Medicine's Committee on Improving Nursing Home
Care for a study to determine the scope and design of an information
system useful for regulating nursing homes effectively and considering
policies for long-term care (Institute of Medicine, 1986~. Quality of
care represents a major interest; the results will also be valuable for
other data systems.
A concerted effort is needed to develop quality of care measures
on the elderly suitable for national information systems. A task force
should be established to serve as the locus for this effort. The task
force could be the responsibility of the National Committee on Vital
and Health Statistics, the Health Information Policy Council in the
Department of Health and Human Services, or the Forum on Aging-
Related Statistics, the coordinating council of principal government
agencies concerned with the provision and use of information on ag-
ing. Special expertise and experience will be required, and the task
force activity will need to be paralleled by funding of methodological
studies through research grants and contracts. The task force should
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QUALITY OF CARE
133
be concerned with assessments of structure, process, and outcome
of care for subgroups of the population, with a special emphasis on
outcomes of care influenced by delivery system and provider char-
acteristics. Consideration should be given to measures and methods
that have the capability of identifying rapidly possible effects of
health policy decisions.
Items contained in several of the national health surveys can
be used as building blocks for developing quality of care measures.
Candidates are found in the NHIS and its supplement on aging and
prevention, the NNHS, the NHANES, and the NAMCS, all of which
are NCHS surveys; in the Long-Term Care Survey (HCFA and the
Office of the Assistant Secretary for Health, DHHS), and in the
forthcoming NMES (NCHSR and HCFA). These items should be
reexamined for modification, amplification, and replacement based
on results of analysis.
Recommendation 6.1: The pane! recommends that agen-
cies having cognizance of national data systems, whether
based on adrn~nistrative records or survey data: (1) jointly
review these data systems to identify items that can be used
in developing quality of care measures and identify missing
items that are needed to produce such measures and (2)
make provision for collecting the data needed to fill gaps
and for producing quality of care measures.
Priority should also be given to development of new items on func-
tional status (as recommended in Chapter 3) and their adoption once
they have been tested. The Long-Term Health Care Minimum Data
Set (discussed in Chapter 7), should be incorporated into relevant
data systems. Appendix D lists the items contained in this minimum
data set.
Indicators of quality of care can also be developed by linking data
obtained in surveys to other files, such as the National Death Index,
or by reinterviews to obtain information on a completed episode of
illness.
Recommendation 6.2: The pane] recommends that multi-
pie data sources be linked to provide indicators of quality
of care during episodes of illness and that continuous, Ton-
gitudinal data be developed to track the flow of individuals
through episodes of illness to recovery, dependency, or death,
including their patterns of use of acute ant] Tong-term care
facilities and community and home care services.
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
Continued support should be ensured for steps already taken, such as
the conduct of the National Mortality Followback Survey; provision
for searches of the National Death Index over long periods for deaths
among people identified in sample surveys of the NCHS; and follow-
up of individuals in the NHANES, the NHIS, and the Long-Term
Care Survey; HCFA's Medicare Automatic Data Retrieval System
should be completed and continued annually; quality of care assess-
ments of hospital prospective payment systems need to be concerned
with pre- and post-hospital care; and urgent attention should be
given to the introduction of severity of illness measures.
The pane! recognizes that most elderly are capable of responding
for themselves when interviewed, but it is uncertain whether issues
affecting the quality of information provided by them are similar or
different from those at younger age groups e Interviewers encounter
additional data quality problems in surveying the elderly because,
with advancing age and for many in nursing homes, the number of
cognitively impaired people increases and the interviewer is depen-
dent on proxy respondents. The validity of data from proxies may
be affected by many factors not well understood at this time. Re-
search on these issues will need to address not only the magnitude
and characteristics of the problems involved, but also the methods
and sources for improving the quality of the data.
Recommendation 6.3: The panel recommends that the Na-
tional Center for Health Statistics develop methods for in-
creasing the validity and reliability of health data (health
status, needs, and care received) collected in surveys of the
elderly, whether from elderly respondents themselves, from
their caregivers or next-of-kin, or from both.
Representative terms from entire chapter:
care measures
