“While quality indicators undoubtedly encourage effective, evidence-based health care overall, they may have the opposite effect when they are applied over-zealously to older patients with medically complex conditions,” said Lee, an assistant adjunct professor of geriatrics at the University of California, San Francisco.
In a Commentary published in the Oct. 5 issue of the Journal of the American Medical Association, Lee highlights two reasons that existing quality indicators may cause more harm than good among the elderly.
First, quality indicators are unbalanced, he says, tending to encourage more health interventions in general “without discouraging inappropriate interventions.” For example, indicators for hypertension control call for blood pressure standards that, when applied too aggressively to elders whose blood pressure is already low, might result in dizziness that in turn could lead to dangerous falls. Similarly, standards for blood glucose control in diabetes care might result in vulnerable older patients experiencing episodes of hypoglycemia, or dangerously low blood sugar.
“We need to look at who is being over-controlled,” said Lee. “If we have measures that target not only appropriate levels of control but include indicators of over-control, we can then encourage hospitals, clinics and doctors to target care to individual patients based on their individual needs and, hopefully, hit the sweet spot of appropriate control.”
The second way that quality indicators may harm the elderly, Lee says, is by promoting unnecessary screening procedures among patients not likely to live long enough to benefit from the screenings.
“Most screenings, such as those for colorectal or breast cancer, are designed to catch and prevent a disease that will occur between five and 10 years in the future,” Lee said. “Patients with life expectancies of less than that are unlikely to benefit from the procedure, and in fact are more likely to be harmed by worry, by unnecessary treatments, and even by the procedure itself.” As a solution, he said, “I propose that we incorporate life expectancy specifically into quality indicators governing screening.”
In revising quality indicators, Lee says, “we have to keep in mind that as people get older, the spread of life expectancy gets much wider, and so health care decisions need to be made on a more individual basis.” The vast majority of people in their 20s and 30s are healthy, he said, and so have about the same statistical chance of reaching old age. “But in a group of 75-year-olds, some might have a life expectancy of less than five years, while others might live more than 15 years. While they are all the same age, they have very different health care needs, and our quality indicators need to reflect that.”
Lee noted that by the year 2030, adults over 65 will account for half of all health care expenditures in the United States. “As the largest consumers of health care, they are the ones with the most to lose from failings in the current system, and the most to gain from making it better.”
The co-author of the Commentary is Louise C. Walter, MD, a geriatrician at SFVAMC and an associate professor of medicine at UCSF.
SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.
UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.