Selecting target conditions for quality of care improvement in vulnerable older adults

OBJECTIVE: To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnera ble older adults. DESIGN: Discussion and two rounds of ranking of conditions by a panel of ge riatric clinical experts informed by literature reviews. METHODS: A list of 78 conditions common among vulnerable older people was r educed to 35 on the basis of their (1) prevalence, (2) impact on health and quality of life, (3) effectiveness of interventions in improving mortality and quality of life, (4) disparity in the quality of care across providers and geographic areas, and (5) feasibility of obtaining the data needed to test compliance with quality indicators. A panel of 12 experts in geriatric care discussed and then ranked the 35 conditions on the basis of the same five criteria. We then selected 21 conditions, based on panelists' iterativ e rankings. Using available national data, we compiled information about pr evalence of the selected conditions for community-dwelling older people and older nursing home residents and estimated the proportion of inpatient and outpatient care attributable to the selected conditions. RESULTS: The 21 conditions selected as targets for quality improvement amon g vulnerable older adults include (in rank order): pharmacologic management ; depression; dementia; heart failure; stroke (and atrial fibrillation); ho spitalization and surgery; falls and mobility disorders; diabetes mellitus; end-of-life care; ischemic heart disease; hypertension; pressure ulcers; o steoporosis; urinary incontinence; pain management; preventive services; he aring impairment; pneumonia and influenza; vision impairment; malnutrition; and osteoarthritis. The selected conditions had mean rank scores from 1.2 to 3.8, and those excluded from 4.6 to 6.9, on a scale from 1 (highest rank ing) to 7 (lowest ranking). Prevalence of the selected conditions ranges fr om 10 to 50% among community-dwelling older adults and from 25 to 80% in nu rsing home residents for the six most common selected conditions. The 21 ta rget conditions account for at least 43% of all acute hospital discharges a nd 33% of physician office visits among persons 65 years of age and older. Actual figures must be higher because several of the selected conditions (e .g., end-of-life care) are not recorded as diagnoses. CONCLUSIONS: Twenty-one conditions were selected as targets for quality imp rovement in vulnerable older people for use in a quality measurement system . The 21 geriatric conditions selected are highly prevalent in this group a nd likely account for more than half of the care provided to this group in hospital and ambulatory settings.