Does better quality of care for falls and urinary incontinence result in better participant-reported outcomes?

Abstract

Objectives: To determine whether delivery of better quality of care for urinary incontinence (UI) and falls is associated with better participant-reported outcomes.

Design: Retrospective cohort study.

Setting: Assessing Care of Vulnerable Elders Study 2 (ACOVE-2).

Participants: Older (≥ 75) ambulatory care participants in ACOVE-2 who screened positive for UI (n = 133) or falls or fear of falling (n=328).

Measurements: Composite quality scores (percentage of quality indicators (QIs) passed per participant) and change in Incontinence Quality of Life (IQOL, range 0-100) or Falls Efficacy Scale (FES, range 10-40) scores were measured before and after care was delivered (mean 10 months). Because the treatment-related falls QIs were measured only on patients who received a physical examination, an alternative Common Pathway QI (CPQI) score was developed that assigned a failing score for falls treatment to unexamined participants.

Results: Each 10% increment in receipt of recommended care for UI was associated with a 1.4-point improvement in IQOL score (P = .01). The original falls composite quality-of-care score was unrelated to FES, but the new CPQI scoring method for falls quality of care was related to FES outcomes (+0.4 points per 10% increment in falls quality, P = .01).

Conclusion: Better quality of care for falls and UI was associated with measurable improvement in participant-reported outcomes in less than 1 year. The connection between process and outcome required consideration of the interdependence between diagnosis and treatment in the falls QIs. The link between process and outcome demonstrated for UI and falls underscores the importance of improving care in these areas.

Figure 1

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 UTI = Urinary tract infection * Patients with positive screens for both UI and falls were considered in both samples. There were 115 (4.3% of screened sample of 2671) with positive UI and falls/fear of falling screens. After exclusions, the final analytic sample included 55 patients who screened positive for both conditions (17% of the falls sample and 41% of the UI sample). ** The original scoring method did not evaluate whether or not appropriate treatment was delivered to 241 patients who were not examined for falls or fear of falling. The Common Pathway Quality Indicator (CPQI) scoring method assumes that patients with no examination documentation had an abnormal examination and evaluates treatment for these patients.

Figure 2. Predicted Patient-reported UI and Falls Outcomes in Relation to UI and Common Pathway Falls Quality Scores

IQOL = Incontinence Quality of Life Score. The IQOL ranges from 0 to 100. On this figure, a higher IQOL change score (higher on the y-axis) corresponds to more improvement (or less worsening if a negative number). A 5 percentage-point difference in IQOL has been correlated in a past study of incontinence outcomes with those who reported at least 25% improvement in incontinence episode frequency FES = Falls Efficacy Score. The FES score ranges from 10 to 40. On this figure, a higher FES change score (higher on the y-axis) corresponds to more improvement (or less worsening if a negative number). A 1.4 point difference in scores was reported in a prior multi-pronged intervention to prevent falls. ACOVE-2 = Assessing Care of Vulnerable Elders Study-2 * Both regression models are controlled for age, gender, number of falls or UI QIs, number of all ACOVE-2 QIs (a proxy for overall level of co-morbidity), time difference, and fixed effects of primary care physician. The falls analysis employed the “Common Pathway” Quality Indicator (CPQI) scoring method that combined the two falls treatment QIs into a single QI (expanded to include all patients irrespective of whether a falls examination was performed, and passed if either treatment was recommended). An interaction term between the quality score and intervention effect was tested and retained in the falls model (less effect in the intervention group of borderline significance, p=.10) but not the UI model (p=.8). 95% confidence intervals are the 5^th and 95^th percentile predicted scores obtained by bootstrapping the multiply-imputed data 1000 times. Predicted FES and IQOL change scores are for a woman (modal gender) at age 80, receiving care at a control practice over the mean observation time (9.8 months for UI, 10.4 months for falls), the mean number of falls or UI QIs triggered (4 for UI, 3 for falls) and the mean number of QIs triggered for all ACOVE-2 conditions (38 for UI, 22 QIs for falls). The arrows correspond to the mean quality scores that were achieved in the ACOVE-2 intervention for intervention versus control groups. The improvement in the CPQI score for falls (20% versus 40% for intervention versus control) was associated with a response of .8 FES points, whereas the improvement in UI quality score (23% versus 41%) was associated with a response of 2.5 IQOL points.