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VA was among the first health systems to
recognize how aging would impact care and
costs, and, presciently, it prepared by adopting
innovative approaches to research, education,
and clinical care. Recently, national policies
and customer demand have stimulated new
measures focusing on providing care in more
home-like settings that better match the
needs and values of patients and families.
Those of us who care for older veterans
feel passionately about the approaches that
VA has adopted. Yet, when we step into
our administrative or research personae,
questions linger. Who really benefits? What
will it cost? Is it sustainable? Could our
finite resources be used in better ways?
The “market-based” indicators outside VA
are discouraging—with the exception of
academic settings (where graduate medical
education requirements demand minimal
exposure to model geriatric care), the
numbers of practicing geriatricians have
been declining.
For the researcher or administrator seeking
to define better care for aging veterans,
three principles are key.
First, we must get further into the
"black box" of our interventions. VA’s
care delivery is based on a model of primary
care, which has been indisputably effective
in improving the quality and
coordination of our care. Yet, a dozen years
ago, a VA-sponsored multi-site trial showed
this intervention increased, rather than reduced,
the use of inpatient care. VA did not
abandon primary care based on these results,
but ongoing work continues to probe
deeper to better understand how structures
(e.g., makeup of teams) and processes of
care (e.g., fidelity to evidence-based practices)
determine outcomes.
Models of geriatric care demand similar
scrutiny. At one time, home-based primary
care and comprehensive geriatric assessment
were considered the “magic bullets”
of caring for complex older patients—yet
trials within VA have shown either modest
benefits or substantial costs.1,2
As with primary care, we now must "muddle
through"—probing with quantitative
and qualitative methods to understand what
aspects of care make a difference, and
which patients benefit. In the absence of an
accepted "gold standard," much variation
exists across VA in geriatric care. Harnessing
that variation for self-inquiry requires
that the entire delivery system be engaged in
practice-based learning.
Second, complex chronic illness, not
aging itself, is the challenge. A century
of geriatric bioscience has demonstrated
that age is a poor surrogate for physiological
function, and that the stronger determinant
of quality of life is chronic illness. But there
is growing evidence that care focused on
only a single disease leads to inadequate attention
to other problems, to the patient’s
detriment. Our knowledge base for managing
complex, co-occurring problems is
sparse, and demands response from the research
community.
New methods of inquiry, such as "real
world" trials that do not exclude patients
with comorbid illness, and large scale observational
studies that tap into electronic
health records, are needed to understand
such complexity. The physical and psychological
effects of combat trauma surely have
impact over the lifespan and must be studied—in both older and younger veterans.
Third, meaningful quality measures
must be developed and validated. Arguably,
the greatest contributor to VA’s quality
transformation over the past decade has
been the systematic use of evidence-based
measures of quality. Quality measures have
also been used as surrogate outcome measures
to test delivery system innovations. Little
is known about measuring the quality of
care rendered to patients with complex,
chronic illness, and concerns have been
raised that individual metrics may be inappropriate
for frail elderly. Recently, RAND
investigators constructed a quality index
from 21 process-of-care indicators and
showed its association with survival among
older managed care patients.3
While the RAND population was not as
frail as VA’s, and not all measures would be
relevant to older veterans, the potential utility
of the RAND approach is obvious. The
major barrier to executing such an approach,
the burden of collecting multi-dimensional
indicators, could be substantially
mitigated through appropriate use of VA’s
electronic health record.
- Cohen HJ, et al. A Controlled Trial of Inpatient and
Outpatient Geriatric Evaluation and Management. New
England Journal of Medicine 2002; 346(12):905-12.
- Hughes SL, et al. Effectiveness of Team-Managed
Home-based Primary Care: a Randomized Multicenter
Trial. Journal of the American Medical Association 2000;
284:2877-85.
- Higashi T, et al. Quality of Care is Associated with
Survival in Vulnerable Older Patients. Annals of Internal
Medicine 2005; 143:274-81.
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