Health Outcomes for Older People Questions for the Coming Decade (1996) / Chapter Skim
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RECOMMENDATIONS: RESEARCH ISSUES
RECOMMENDATIONS: RESEARCH ISSUES
Pages 15-44
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From page 15... ...
People have different preferences for different outcomes, and those differences need to be identified and, whenever possible, honored. To support those efforts, the committee recommends that the following 10 areas receive concentrated attention over the next 10 years: Health-Related Quality of Life Satisfaction with Care "Toolbox" of Outcomes Measures and a Core Set of Outcomes Measures Practice Patterns and Interventions and Their Effect on Outcomes Involvement in Care Decisionmaking Education and Dissemination of Outcomes Information Financing Systems Service Delivery and Utilization Transitions Quality Assessment and Improvement 15
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. Functional health status is a significant dimension of health-related quality of life for older individuals.
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Some instruments, such as the Health Utility Index, do incorporate health states worse than death and are beginning to be more widely used. Functional Health Status Functional health status is an important dimension of health-related quality of life.
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The committee did not, however, attempt to prioritize which specific clinical conditions should be examined within the next 10 years. Such prioritization has been done before, however.
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· Examine how current and new measures of functional health status help differentiate health care plans and practitioners. · Compile measures of functional health status and evaluate their appropriateness for use with older individuals.
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· Despite progress, available measurement tools and analytic methods of interpreting satisfaction with care can lead to spurious interpretations and conclusions. Background Measuring Satisfaction Several instruments already exist to measure overall ratings of care (i.e., asking patients to rate their care as either "poor to excellent" or to say whether they are "very dissatisfied" or"very satisfied"~.
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noted that seriously ill patients will report both severe pain and high levels of satisfaction with their pain control. A better understanding of people's expectations might help explain this seeming
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· Examine how current and new measures of satisfaction help differentiate health care plans and practitioners.
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A variety of health outcomes measures exist, but many may not have been tested specifically for older people, particularly for those with cognitive or communicative impairments. · Use of a core set of outcomes measures can provide the basis for making clinically relevant care planning decisions, whether by hospital, home health agency, nursing home staff, primary care practitioner, patient, or family caregiver.
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Other groups that pose a methodologic challenge include individuals in various types of residential facilities, individuals from ethnic minorities for whom English is not a first language, and very old individuals. Core Set of Outcomes Measures A great deal of data about patient outcomes is already being collected.
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The measures should be able to be tracked over time. For example, patients with chronic obstructive pulmonary disease should be able to compare the functional health status of similar patients within and across different health plans.
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Background Examining the link between specific practice patterns and health-related interventions and health status has been a traditional focus of health outcomes research. Yet even when practice patterns or interventions have been linked to good outcomes, wide variations in their use has been documented.
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These efforts have resulted in the development and promotion of numerous clinical practice guidelines, extended care pathways, and disease management programs. Clinical practice guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances" (IOM, 1990c, p.
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. Test various methods to promote the use of clinical practice guidelines and other, perhaps more forceful, approaches for changing practice patterns and use of certain interventions.
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It is also important in achieving cooperation between professionals and patients in ongoing therapy for chronic conditions. The committee hopes that this trend of greater involvement will continue but also cautions that the basic assumption that this involvement both is wanted by older individuals and leads to better health outcomes must be investigated.
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· Improve models that portray treatment benefits while taking into account competing risks and the likelihood of various events occurring. Establish methods of measuring patient preferences for various functional outcomes and examine how those preferences might change over time.
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These educational resources also allow practically anyone to utilize the results of health outcomes research from an older woman with breast cancer "surfing" the Internet for the latest information about treatment options to a daughter looking over performance reports of nursing facilities as she decides the most appropriate one for a parent suffering from Alzheimer's disease. The content and method of disseminating such information will obviously need refinement.
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· Examine how personal style and involvement in decisionmaking about care affect an individual's satisfaction and functional health status. Refine the content and method of disseminating health outcomes information.
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currently pays an average annual per capita cost (AAPCC) , based on an average cost per fee-for-service beneficiary in a geographic area (with certain adjustments for age, gender, disability status, and nursing home residence)
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, and others are as yet untried. Risk Adjustment Even though they tend to have more health problems than younger people, older people vary considerably in their health status and in the economic risks they pose to capitated health plans.
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Conduct randomized controlled trials and quasi-experiments to test the incentives and costs of different models of reimbursement and their effect on integration and coordination of services, cost-effectiveness, and health outcomes of older individuals and their families. Conduct policy research to determine the impact on health outcomes of adverse and favorable selection in health plans.
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. More fully integrated care delivery systems offer the potential of providing new and improved services, which could, in turn, improve health outcomesespecially for people with chronic conditions.
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For example, early indications from one study suggest that the probability of hospitalization for nursing home patients is substantially higher in markets with more beds per 1,000 and lower hospital occupancy rates (Mor, 1996~. Similarly, the use of nursing facilities, assisted living facilities, and home health services has been shown to vary enormously by region and appears to be linked to the number and availability of these services (Delfosse, 19959.
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· Evaluate whether more fully integrated care delivery systems actually provide new and improved services and, thereby, improve health outcomesespecially for people with chronic conditions. · Determine how older individuals' health outcomes are affected by (a)
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From page 39... ...
Older adults often experience complex health patterns, undergoing multiple stages of deterioration and improvement in their health, even during a single episode of care. Background There is a misperception that as people age they move along a linear continuum of care as their status gradually and smoothly changes from that of a well, active, and independent senior living in the community to that of a completely dependent nursing home resident.
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These changes raise questions about whether they may disrupt patterns of care and, ultimately, affect health outcomes of older people. Examples of such changes are many: physicians retire or become employees, begin to use nurse practitioners and case managers, or become part of an interdisciplinary team; physicians sometimes do not follow their patients' care into the nursing home; hospitals or clinics close; use of telephone triage may be implemented (which could have a particularly adverse effect on older individuals, who might have greater difficulty hearing or quickly comprehending verbal information)
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. 41 Rationale Governments, private-sector accreditation organizations, and health care delivery organizations are increasingly using outcomes measures as a basis for assessing and improving the quality of care.
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For example, using certain kinds of health outcomes measures-or failing to adjust outcomes for severity of illness and comorbidities may discourage health care organizations from serving the sickest patients. Examples of Needed Research .
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Pain and Satisfaction with Pain Control in Seriously Ill Hospitalized Adults Findings from SUPPORT Critical Care Medicine, forthcoming. GAO (General Accounting Office)
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Mor, V Using Global and Targeted Outcomes Measures in Applied Settings.
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