Relationship between quality of care and functional decline in hospitalized vulnerable elders

Abstract

Background: Although process of care is a valuable dimension of quality, process-of-care-based quality indicators (POC-QIs) are ideally associated with meaningful patient outcomes. The relationship between POC-QIs for hospitalized older patients and functional decline, a relevant outcome for older patients, is unknown.

Objective: To assess the relationship between POC-QIs for hospitalized elders and functional decline.

Research design: Observational cohort study.

Subjects: Hospitalized vulnerable elder patients age 65 or older admitted to a general medicine inpatient service from June 1, 2004 to June 1, 2007.

Measures: POC-QIs received by hospitalized patients (measured by Assessing Care of Vulnerable Elders QIs) and functional decline (increased activities of daily living impairments postdischarge).

Results: For 898 vulnerable elder patients, mean adherence to 6 universally applied quality indicators was 57.8%. After adjustment for factors likely associated with functional decline (comorbidity, vulnerability, baseline functional limitation, number of POC-QIs triggered, length of stay, code status, and interaction between frailty and QI adherence), there was no association higher quality of care (using the composite score) and increased risk of functional decline. Patients who received a mobility plan were 1.48 (95% CI: 1.07-2.05; P = 0.017) times more likely to suffer functional decline after discharge. Patients who received an assessment of nutritional status had a lower odds of suffering functional decline after discharge (OR: 0.37, [95% CI: 0.21-0.64; P < 0.001]).

Conclusions: Hospitalized vulnerable elders who receive higher quality of care, as measured by Assessing Care of Vulnerable Elders QIs, are not less likely to suffer decline after discharge.

Figure 1

Patient recruitment to and exclusion from study.

Appendix Figure 1

Patients Reporting Functional Decline Over Time Periods (n = 898) (a) Admission to discharge; (b) Admission to one month after discharge; (c) One month before admission to discharge; (d) One month before admission to one month after discharge *Patients experiencing functional decline [emergence of deficits in 1 or more Activities of Daily Living (ADLs)] in given time period, n (%) †Patients experiencing catastrophic functional decline are in italics (emergence of deficits in 3 or more ADLs) in given time period, n (%) ‡At inpatient interview, patients were asked to retrospectively recall their functional status one month prior to admission §At post-discharge phone survey, patients were asked to retrospectively recall their functional status at the time of discharge from the hospital