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The geriatrics research program at San Francisco VA Medical Center, already respected as one of the most innovative and influential in the United States, received an additional boost in October 2011 when two articles by SFVAMC physician-researchers appeared in the Journal of the American Medical Association (JAMA), the leading medical journal in the country. 

In a Commentary published in the October 5 issue, Sei Lee, MD, MAS, highlighted ways in which quality indicators may hurt, rather than help, older patients. Quality indicators are measurements used by insurers and health care systems to gauge the quality of patient care.

First, said Dr. Lee, quality indicators are “unbalanced,” meaning that they tend to encourage health interventions in general “without discouraging inappropriate interventions,” such as hypertension control for elders whose blood pressure is already low, or strict blood sugar control for diabetic elders who are at risk for hypoglycemia (low blood sugar).

Second, quality indicators promote unnecessary health screening procedures. “Screenings for colorectal or breast cancer are designed to catch and prevent a disease that will occur in five or ten years,” said Dr. Lee. “Patients with life expectancies of less than that are unlikely to benefit, and in fact are more likely to be harmed by worry, unnecessary treatments, and even the procedure itself.” As a solution, he said, “I propose that we incorporate life expectancy specifically into quality indicators governing screening.”

Writing in the October 26 issue of JAMA, Kenneth E. Covinsky, MD, MPH, reviewed the case history of a 70-year-old patient who lived independently before hospitalization but became permanently disabled afterwards, despite successful treatment of her medical illnesses.

“If you are over the age of 70, chances are one in three that if you go into the hospital, you will come out with a major new disability that threatens your ability to live without assistance,” said Dr. Covinsky. He used the patient’s story as a point of departure to discuss why hospital-associated disability occurs and some possible ways to prevent it.

“For older people, hospitalization can become an episode of forced dependence,” said Dr. Covinsky. “They’re put in bed, their clothes are taken from them, their meals are brought to them, and very often, they will not get out of bed for days at a time. This has long-term effects on their ability to function for themselves.” Urinary catheters and IV poles – which are standard, but often unnecessary – also contribute to immobility.

To prevent the onset of disability in their elderly patients, the authors recommend that hospitals adopt treatment methods that focus on maintaining function, such as Acute Care for Elders (ACE) units, based on a model developed by Seth Landefeld, MD, SFVAMC Chief of Geriatrics.

“Our job,” concluded Dr. Covinsky, “is to help our patients maintain independence to whatever extent we can.”


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January 28, 2019