Is patient-perceived severity of a geriatric condition related to better quality of care?

Abstract

Background: Care for falls and urinary incontinence (UI) among older patients is inadequate. One possible explanation is that physicians provide less recommended care to patients who are not as concerned about their falls and UI.

Objective: To test whether patient-reported severity for 2 geriatric conditions, falls, and UI, is associated with quality of care.

Research design: Prospective cohort study of elders with falls and/or fear of falling (n = 384) and UI (n = 163).

Subjects: Participants in the Assessing Care of Vulnerable Elders-2 Study (2002-2003), which evaluated an intervention to improve the care for falls and UI among older (age, ≥ 75) ambulatory care patients with falls/fear of falling or UI.

Measures: Falls Efficacy Scale (FES) and the Incontinence Quality of Life surveys measured at baseline, quality of care measured by a 13-month medical record abstraction.

Results: There was a small difference in falls quality scores across the range of FES, with greater patient-perceived falls severity associated with better odds of passing falls quality indicators (OR: 1.11 [95% CI: 1.02-1.21] per 10-point increment in FES). Greater patient-perceived UI severity (Incontinence Quality of Life score) was not associated with better quality of UI care.

Conclusions: Although older persons with greater patient-perceived falls severity receive modestly better quality of care, those with more distressing incontinence do not. For both conditions, however, even the most symptomatic patients received less than half of recommended care. Low patient-perceived severity of condition is not the basis of poor care for falls and UI.

Figure 1. Flow Diagram of

Enrollment and Quality of Care Measurement for Falls and Urinary Incontinence Patients in the Assessing the Care of Vulnerable Elders (ACOVE-2) Study FES = Falls Efficacy Scale IQOL = Incontinence Quality of Life survey UI = Urinary Incontinence QI = Quality indicator * Patient with positive screens for both UI and falls were considered in both samples. There were 115 (4.3% of unscreened sample of 2671) with positive UI and falls/fear of falling screens. After exclusions, the final analytic sample included 69 of these patients (18% of the falls sample and 42% of the UI sample).

Figure 2

Probability* of Passing Falls and UI Quality Indicators * Predicted probabilities are based upon a multivariable logistic regression that controlled for intervention versus control group, interaction between FES score or rIQOL score and intervention versus control group, age, gender, number of QIs triggered, and secondary versus primary QI. Displayed predicted values are for an 81-year old woman in the control group triggering a primary QI. 95% confidence intervals were obtained by bootstrapping. ** FES score was rescaled to range from 0 to 100 (higher is more fear of falling). Median FES scores was 30 (interquartile range 13–53). ‡Reversed IQOL scores range from 0 to 100 (higher is more symptomatic). Median rIQOL score was 23 (interquartile range 11–40). FES = Falls Efficacy Score IQOL = reversed Incontinence Quality of Life UI = Urinary Incontinence QIs = Quality Indicators