Development of quality indicators for monitoring outcomes of frail elderly hospitalised in acute care health settings: Study Protocol

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Abstract

Background

Frail older people admitted to acute care hospitals are at risk of a range of adverse outcomes, including geriatric syndromes, although targeted care strategies can improve health outcomes for these patients. It is therefore important to assess inter-hospital variation in performance in order to plan and resource improvement programs.

Clinical quality outcome indicators provide a mechanism for identifying variation in performance over time and between hospitals, however to date there has been no routine use of such indicators in acute care settings.

A barrier to using quality indicators is lack of access to routinely collected clinical data. The interRAI Acute Care (AC) assessment system supports comprehensive geriatric assessment of older people within routine daily practice in hospital and includes process and outcome data pertaining to geriatric syndromes.

This paper reports the study protocol for the development of aged care quality indicators for acute care hospitals.

Methods/Design

The study will be conducted in three phases:

1. Development of a preliminary inclusive set of quality indicators set based on a literature review and expert panel consultation,

2. A prospective field study including recruitment of 480 patients aged 70 years or older across 9 Australian hospitals. Each patient will be assessed on admission and discharge using the interRAI AC, and will undergo daily monitoring to observe outcomes. Medical records will be independently audited, and

3. Analysis and compilation of a definitive quality indicator set, including two anonymous voting rounds for quality indicator inclusion by the expert panel.

Discussion

The approach to quality indicators proposed in this protocol has four distinct advantages over previous efforts: the quality indicators focus on outcomes; they can be collected as part of a routinely applied clinical information and decision support system; the clinical data will be robust and will contribute to better understanding variations in hospital care of older patients; The quality indicators will have international relevance as they will be built on the interRAI assessment instrument, an internationally recognised clinical system.

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Most cited references 26

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The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community.

D. Saliba, M. Elliott, L Rubenstein … (2001)

To develop a simple method for identifying community-dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self-reported diagnoses and conditions add predictive ability to a function-based survey. Analysis of longitudinal survey data. A nationally representative community-based survey. Six thousand two hundred five Medicare beneficiaries age 65 and older. Bivariate and multivariate analyses of the Medicare Current Beneficiary Survey; development and comparison of scoring systems that use age, function, and self-reported diagnoses to predict future death and functional decline. A multivariate model using function, self-rated health, and age to predict death or functional decline was only slightly improved when self-reported diagnoses and conditions were included as predictors and was significantly better than a model using age plus self-reported diagnoses alone. These analyses provide the basis for a 13-item function-based scoring system that considers age, self-rated health, limitation in physical function, and functional disabilities. A score of >or=3 targeted 32% of this nationally representative sample as vulnerable. This targeted group had 4.2 times the risk of death or functional decline over a 2-year period compared with those with scores <3. The receiver operating characteristics curve had an area of.78. An alternative scoring system that included self-reported diagnoses did not substantially improve predictive ability when compared with a function-based scoring system. A function-based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self-reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function-based targeting system relies on self-report and is easily transported across care settings.

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Assessing quality using administrative data.

Lisa Iezzoni (1997)

Administrative data result from administering health care delivery, enrolling members into health insurance plans, and reimbursing for services. The primary producers of administrative data are the federal government, state governments, and private health care insurers. Although the clinical content of administrative data includes only the demographic characteristics and diagnoses of patients and codes for procedures, these data are often used to evaluate the quality of health care. Administrative data are readily available, are inexpensive to acquire, are computer readable, and typically encompass large populations. They have identified startling practice variations across small geographic areas and-supported research about outcomes of care. Many hospital report cards (which compare patient mortality rates) and physician profiles (which compare resource consumption) are derived from administrative data. However, gaps in clinical information and the billing context compromise the ability to derive valid quality appraisals from administrative data. With some exceptions, administrative data allow limited insight into the quality of processes of care, errors of omission or commission, and the appropriateness of care. In addition, questions about the accuracy and completeness of administrative data abound. Current administrative data are probably most useful as screening tools that highlight areas in which quality should be investigated in greater depth. The growing availability of electronic clinical information will change the nature of administrative data in the future, enhancing opportunities for quality measurement.

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Functional outcomes of acute medical illness and hospitalization in older persons.

C. Seth Landefeld, M. Sağer, M Rudberg … (1996)

Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization. A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning. At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized. This study documents a high incidence of functional decline after hospitalization for acute medial illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Health Serv Res

Title: BMC Health Services Research

Publisher: BioMed Central

ISSN (Electronic): 1472-6963

Publication date Collection: 2011

Publication date (Electronic): 20 October 2011

Volume: 11

Page: 281

Affiliations

[1 ]Department of Clinical Epidemiology, Biostatistics and Health Services Research, Melbourne Health, The University of Melbourne and The Royal Melbourne Hospital, Melbourne, Australia

[2 ]Department of Medicine, University of Melbourne, Parkville, Victoria, Australia

[3 ]Centre for Research Excellence in Patient Safety (CREPS) Monash University, Melbourne, Victoria, Australia

[4 ]Centre for Research in Geriatric Medicine, The University of Queensland School of Medicine, Woolloongabba, Queensland, Australia

[5 ]Nutrition and Dietetics, School of Human Movement Studies, The University of Queensland, St Lucia, Australia

[6 ]Harvard Medical School, Cambridge, Massachusetts, USA

[7 ]Institute of Ageing Research, Boston, Massachusetts, USA

Article

Publisher ID: 1472-6963-11-281

DOI: 10.1186/1472-6963-11-281

PMC ID: 3212964

PubMed ID: 22014061

SO-VID: 7645bc6f-a2be-4772-b67a-1a54eacc22d5

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Development of quality indicators for monitoring outcomes of frail elderly hospitalised in acute care health settings: Study Protocol

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Abstract

Background

Methods/Design

Discussion

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Most cited references 26

The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community.

Assessing quality using administrative data.

Functional outcomes of acute medical illness and hospitalization in older persons.

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