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Quality of Care Is Associated with Survival in Vulnerable Older Patients

Takahiro Higashi, MD, PhD; Paul G. Shekelle, MD, PhD; John L. Adams, PhD; Caren J. Kamberg, MSPH; Carol P. Roth, RN, MPH; David H. Solomon, MD; David B. Reuben, MD; Lillian Chiang, MD; Catherine H. MacLean, MD, PhD; John T. Chang, MD, MPH; Roy T. Young, MD; Debra M. Saliba, MD, MPH; and Neil S. Wenger, MD, MPH
[+] Article, Author, and Disclosure Information

From RAND Health, Santa Monica, California, and Washington, DC, and the University of California, Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California.

Acknowledgments: The authors thank Robert Brook, MD, ScD, for inspiration and guidance; Robin P. Hertz, PhD, senior director of outcomes research and population studies at Pfizer Inc, for providing valuable support; and Patricia Smith and Victor Gonzalez for their technical assistance.

Grant Support: Supported by a contract from Pfizer Inc. Dr. Higashi is supported by a St. Luke's Life Science Institute Fellowship Award. Dr. Shekelle was a Senior Research Associate of the Veterans Affairs Health Services Research & Development Service. Dr. Chiang is supported by a Bureau of Health Professionals Geriatrics Research Faculty Training Program. Drs. MacLean and Saliba are Research Associates of the Veterans Affairs Health Services Research & Development Service. Dr. Chang is supported by a National Research Service Award (PE-19001) and the University of California, Los Angeles, Specialty Training and Advanced Research (STAR) Program.

Potential Financial Conflicts of Interest: Stock ownership or options (other than mutual funds): R.T. Young (Pfizer Inc).

Requests for Single Reprints: Neil S. Wenger, MD, MPH, RAND, 1700 Main Street, Santa Monica, CA 90407.

Current Author Addresses: Dr. Higashi: Department of Epidemiology and Healthcare Research, Kyoto University, Yoshida-konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.

Dr. Chang: Division of General Internal Medicine, University of California, Los Angeles, 911 Broxton Plaza, Los Angeles, CA 90095-1736.

Drs. Shekelle, MacLean, and Saliba: Greater Los Angeles Veterans Affairs Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073.

Drs. Solomon, Adams, and Wenger and Ms. Roth: RAND, 1700 Main Street, M-26, Santa Monica, CA 90407-2138.

Ms. Kamberg: RAND, 1200 South Hayes Street, Arlington, VA 22202.

Dr. Young: Division of General Internal Medicine, University of California, Los Angeles, 200 Medical Plaza, Los Angeles, CA 90095-1736.

Drs. Reuben and Chiang: Division of Geriatrics, University of California, Los Angeles, 200 Medical Plaza, Los Angeles, CA 90095-1736.

Ann Intern Med. 2005;143(4):274-281. doi:10.7326/0003-4819-143-4-200508160-00008
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We found that better quality of care provided to community-dwelling vulnerable older persons was associated with higher 3-year survival. The relationship between quality of care and survival was robust to analysis in several different ways. The process–outcome link remained after weighting for quality score stability and after adjustment for quality indicator difficulty. The alternative explanation, that physicians elect to provide less care to persons on a downward trajectory, is less likely because we did not observe a relationship between care quality and sickness or age. Although our study is observational, our results satisfy most of the factors explicated by Hill (17) for making causal inference in observational studies, the most important of which are strength of association, temporality of the cause and effect, the presence of a dose–response gradient, plausibility of causal mechanisms, coherence with current knowledge, consistency with other studies, and specificity of the association. Our finding of a moderately strong association between process and outcome has no temporal ambiguity between process and outcome, with evidence of a dose–response relationship, and a plausible mechanism of effect that is consistent with current knowledge. Only consistency and specificity of the association are not satisfied by our results. Consistency cannot be tested by only 1 study, and specificity cannot be tested because our only outcome measure is mortality. Furthermore, the formal sensitivity analysis for a potential unmeasured omitted confounder revealed that this confounder must be very strongly related to both quality and survival to explain the quality–survival relationship beyond the adjustment for other covariates. Therefore, we believe that the most plausible interpretation of our results is that the receipt of better-quality care was causally linked with improvement in 3-year mortality in our sample of community-dwelling vulnerable older adults.

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Figure 1.
Kaplan–Meier survival curves for patients grouped into the upper and lower half of quality.

Patients in the upper half of quality received a mean quality score of 62%, and patients in the lower half had a mean quality score of 44%. Survival curves differed by the log-rank test (  = 0.02).

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Figure 2.
Three-year survival for 10 equal intervals of quality score.

Relationship of survival to quality captured in 10 equal intervals (  = 0.77).

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Figure 3.
Relationship between quality score and age (top) and relationship between quality score and Vulnerable Elders Survey-13 (VES-13) score (bottom).
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Quality of care and vulnerability
Posted on September 2, 2005
Stephanie L Garrett
University of Louisville
Conflict of Interest: None Declared


In a recent meeting of our fellows and departmental faculty, we discussed Higashi et al (1). There was considerable excitement because we are committed to quality care for our frail older patients. To our surprise the analyses as presented did not support the conclusions.

The authors state that "˜"¦8 of these 9 quality indicators"¦ patient(s) "¦ receiv(ing) recommended care was less likely to die "¦' (Table 2). Only one of these 9 quality indicators were significant "“ the exact opposite of the text. Pneumococcal vaccine lowered the risk of death by 54% while all the others did not alter risk. Figure 1 comparing high and low quality care groups showed a clear separation only after 800 days. During the first 400 days, the lines are indistinguishable. The authors used the Vulnerable Elders Survey "“ 13 to create the sample. Patients who score a 3 or higher with the VES-13 are at 4 times the risk for death over the next two years (2). During the 3 year follow-up period 23% of patients in the overall sample died. The paper does not report proportion dead within categories of quality score.

The authors use age as a surrogate for severity of illness and see no association with VES-13 (Figure 3). The implication, though not explicitly stated, is that the lack of relationship between age and VES-13 means that no statistical confounding is present. However, in every other report that has ever been published, age is significantly associated with risk of death. The lack of a direct test for association between age and survival is a major oversight.

VES-13 has a selection bias that would systematically label robust persons who are 85 years and older as vulnerable. In the scoring system, anyone who is in this age group gets an automatic 3 points. It would be informative to look at the age distribution within VES-13 groups. We suspect that the persons who are 5 or less are in this subgroup.

The VES-13 appears to do a very good job of identifying persons who are within 1 "“ 2 years of death. Comfort care, goals of care, advance directives are quality indicators for end of life. The lack of association between the ACOVE quality indicators (3) and survival in this sample makes a strong argument for palliative care medicine. Sorting out robust older adults from frail ones will result in quality of care for all.

References 1. Higashi T, Shekelle PG, Adams JL, Kamberg CJ, Roth CP, Solomon DH et al. Quality of care is associated with survival in vulnerable older patients. Ann Intern Med 2005, 143(4): 274 "“ 281. 2. Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ et al. The Vulnerable Elders Survey: A Tool for Identifying Vulnerable Older People in the Community. JAGS 2001 49: 1691 "“ 1699. 3. ACOVE Quality Indicators. Ann Intern Med 2001, 135(8): Part 2 653 "“ 667.

Conflict of Interest:

None declared

In Response:
Posted on November 23, 2005
Takahiro Higashi
Kyoto University Department of Epidemiology and Healthcare Research
Conflict of Interest: None Declared

We interpret the findings very differently than Dr. Garrett and colleagues, although we agree with their conclusion that there is a strong argument for palliative medicine for many of the patients in the study sample. Many of the quality indicators in the ACOVE measurement set focused on pain and end of life care. Dr. Garrett and colleagues state that there is a lack of association between our quality measurement and survival, yet the analyses in the article demonstrate a strong relationship.(1) Their concern that only 1 of 9 of the most prevalent quality indicators (in Table 2) demonstrates a statistically significant relationship between receiving the care process and survival misses the point that these ancillary analyses, which are statistically underpowered and unadjusted, were presented only to provide insight into potential mechanisms of the relationship between process and outcome. We focused on the direction of the point estimates, showing that the relative risk of death for those who passed the quality indicators was below 1 in 8 of the 9 quality indicators. Dr. Garret and colleagues expressed concerns about the selection of community-dwelling vulnerable older persons using the VES-13 and were interested in the age distribution within our sample, especially the proportion of persons 85 years or older among those with a VES-13 score of 5 or less. There were 135 persons 85 years or older, among whom 79 had the VES score of 5 or less. Furthermore, they were concerned about the relationship between age and survival in the studied cohort. The VES-13, which contains age, was a strong predictor of survival, as expected. We share Dr Garrett and colleagues' excitement about our findings of association between quality and survival and their commitment to quality care for older patients.

1 Higashi T, Shekelle PG, Adams JL, et al. Quality of care is associated with survival in vulnerable older patients. Ann Intern Med. 2005;143:274-81.

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Association of Quality of Care with Survival of Elderly Managed Care Patients

The summary below is from the full report titled “Quality of Care Is Associated with Survival in Vulnerable Older Patients.” It is in the 16 August 2005 issue of Annals of Internal Medicine (volume 143, pages 274-281). The authors are T. Higashi, P.G. Shekelle, J.L. Adams, C.J. Kamberg, C.P. Roth, D.H. Solomon, D.B. Reuben, L. Chiang, C.H. MacLean, J.T. Chang, R.T. Young, D.M. Saliba, and N.S. Wenger.


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