Quality of Ambulatory Care for the Elderly: Formulating Evaluation Criteria
Ferris, Ann K., Wyszewianski, Leon, Health Care Financing Review
Quality of ambulatory care for the elderly: Formulating evaluation criteria
The concerns that arose in the early 1980s about the quality of care received by Medicare beneficiaries initially focused on inpatient care (Eggers, 1987) but quickly extended to other types of care, including, in particular, care provided in ambulatory settings. In 1987, peer review organizations (PROs) began to assess, on behalf of the Medicare program, the ambulatory care provided to Medicare patients in health maintenance organizations. In 1989, ambulatory surgical centers became subject to PRO scrutiny, and there are plans to move into other ambulatory care settings as well.
Although there is little information about the basis for all these current and future evaluations of ambulatory care, it is reasonable to expect these assessments to be based mostly on criteria and standards of care in use for the general adult population. So far, however, there is no indication that these general criteria have been adjusted to take into account the characteristics of the elderly, who comprise the vast majority of Medicare beneficiaries.
The purpose of this article is to show why and how assessments of ambulatory care services provided to Medicare beneficiaries should be based on criteria and standards of quality that explicitly reflect the specific needs and salient characteristics of the population 65 years of age or over. To make our task manageable, we have restricted our discussion to what is known as the "technical" aspect of care, which involves the application of medical knowledge to diagnosis and treatment (Donabedian, 1980). The evaluation of the interpersonal aspects and the amenities of care--the nontechnical components--is therefore not included in this discussion.
In addition, although we are concerned with criteria and standards of care in an overall sense, we focus primarily on the basic, initial issue of defining what constitutes appropriate care for the elderly and place relatively less emphasis on the subsequent step of developing specific measures and indicators. As we see it, only after it has been specified what is good and appropriate care is there an issue of what measures or indicators should be used to assess care and what data are needed or available for this purpose.
The need for evaluating ambulatory care provided to the elderly based on criteria and standards that take into account the special characteristics of this population is best illustrated by studies in which the relation between the age of patients and the quality of the care provided have been examined. The results of these studies are contradictory and ambiguous. An important reason for this is that most of the studies did not use criteria and standards that take into account important age-related differences (Wyszewianski and Donabedian, 1981).
For example, in a study by Lyons and Payne (1974), it was shown that patients 65 years of age or over received care for cerebrovascular accidents that had significantly lower scores on the study's measures of quality, even though the authors suggest that care for these patients may have been appropriate if factors often associated with advanced age had been taken into account. In particular, the authors note that cerebrovascular accidents "... are frequently terminal events in the elderly, and little, if any, manipulation or therapeutic intervention will alter the course of events. Physician effort in this context may be cautious or even withheld, especially in a patient with multiple additional diagnoses or disabilities for whom survival may mean only greater disability and societal disruption."
On the other hand, in the same study, Lyons and Payne suggest that the significantly higher scores for care provided to the elderly with bronchitis--as compared with care given to those under 65 years of age--are less a reflection of better physician performance than evidence of physician's response to the need for ". …