Quality Indicators may Lead to Unintended Harm in Elderly Patients with Complex Health Issues
Quality indicators are quantitative measures used to evaluate the quality of healthcare. Often based on clinical practice guidelines, they are designed to encourage effective, evidence-based interventions. But for older patients with complex medical problems, there are concerns that closer adherence to current quality indicators may lead to unintended harms. This is important because by 2030, adults older than age 65 will account for 50% of healthcare expenditures; therefore, older adults will represent the “average” patient in many healthcare settings, and quality indicators must improve care for these patients if they are to improve overall healthcare quality. This article highlights two ways that current indicators may lead to unintended harms and proposes ways to improve quality indicators by minimizing or preventing those harms.
Current quality indicators are unbalanced, with many encouraging more appropriate care but few indicators discouraging inappropriate care. For example, the 2011 HEDIS (Healthcare Effectiveness Data and Information Set) quality indicators for blood pressure control report the percentage of patients with hypertension with BP < 140/90, in order to encourage more appropriate treatment. However, there are no quality indicators measuring the rates of syncope or orthostatic hypotension that would discourage overly aggressive treatment. Cancer screening provides another example. An indicator reporting the rates of inappropriate mammography (e.g., for patients with pre-existing advanced cancer or advanced dementia, who are unlikely to benefit) would encourage targeting screening to healthier women who are most likely to benefit. In addition, quality indicators ignore life expectancy and lagtime-to-benefit for preventive interventions. For example, the HEDIS quality indicator for colorectal cancer would encourage screening for a 70-year-old patient even in the presence of lung disease that limits his life expectancy and makes it unlikely that he would benefit. In healthcare settings with a robust electronic medical record (EMR), such as VA’s, life expectancy could be calculated for every patient using the clinical data within the EMR (i.e., comorbidities and lab values), in order to implement life expectancy-based quality indicators.
Overall, healthcare quality indicators are powerful tools that can change provider behavior and improve patient care. However, current indicators are unbalanced and ignore the lagtime-to-benefit for preventive interventions, leading to unintended harms. Because older adults are the largest consumers of healthcare, they have the most to gain from improving quality indicators. The authors suggest that quality indicators be refined and improved to drive real quality improvement for the entire patient population.
Drs. Lee and Walter are part of HSR&D’s Program to Improve Care for Veterans with Complex Comorbid Conditions in San Francisco, CA. Dr. Lee also is Associate Director of the VA National Quality Scholars Fellowship Program.
Lee S and Walter L. Quality Indicators for Older Adults: Preventing Unintended Harms. JAMA October 5, 2011;306(13):1481-82.