Use of Evidence-Based Practices Needs Improvement Among Aging Population

The Dartmouth Atlas Project recently released “Our Parents, Ourselves: Health Care for an Aging Population,” a report card evaluating the healthcare being provided to the aging US population, noting which areas of the healthcare system has progressed in patient-centered care and which areas still require improvement.

Julie W. Bynum, MD, MPH, and her team reviewed 306 hospital referral regions to see whether or not aging patients were receiving medical care that reflected evidence-based practices. They wrote that it is more important than ever to ensure that care for older adults is well-organized and patient-focused as the elderly US population continues to increase.

“Older adults are more likely than ever to experience frequent, complex interactions with the health care system involving an expanded cadre of providers,” the wrote in the report. “Providers may be unaware of the other health care activities in which an older person may be involved. Understanding how care for older adults is organized and delivered can shed light on whether care could be delivered more efficiently from the patient’s point of view.”

Using Medicare claims data, the report surveyed the demographics of Medicare beneficiaries aged 65-99 years, including race and enrollment status among other characteristics. They also looked at the type of care this population received, the number of providers, and the frequency of contact they had with the health system. Hospital referral regions were selected for their tertiary medical care and greatest proportion of Medicare residents hospitalized.

Significant progress has been achieved for elderly patients in terms of a decline in use of high-risk medicines, an increase in diabetes testing, a reducing in preventable hospital admissions, and a reduction in 30-day readmissions.

Older individuals take more medications and have more vulnerability, and so are at greater risk for adverse drug affects. As such the National Committee for Quality Assurance developed a list of medications to be avoided in prescriptions for elderly adults; the percentage of Medicare beneficiaries who filled a prescription for high-risk medicine has dropped from 32.2% to 18.4% as of 2012.

Due to its association with old age and weight gain, older adults are more at risk for Type 2 diabetes. The American Diabetes Association has recommended 3 additional quality measures for diabetic patients; 53.2% of Medicare beneficiaries received all 3 of these measures as of 2012, compared to 48.1% in the period between 2003 and 2005.

There has also been a decrease in preventable hospital admissions. Although patients may consider a hospital visit a safer choice, better access to primary or other outpatient care could reduce risk of infection, error, and costs to family and society, all of which could result from hospitalization. Preventable hospital admissions dropped from 5.5% in 2003 to 4.2% in 2012.

While some hospital readmissions may be expected or even planned, most are not and result from inadequate discharge planning, poor care coordination, and/or lack of effective longitudinal community-based care. There was a slight decrease in 30-day readmissions from 16.2% to 15.5% between 2008 and 2012.

More Improvement Required

The authors identified several areas of aging adult care that could stand more improvement: screening for prostate cancer, screening for breast cancer, late referral to hospice, provision of feeding tubes in dementia patients, and number of days in intensive care units (ICUs) during last 6 months of life.

Cancer screening has not been recommended for certain age populations—specifically 75 years and older—as the risks generally outweigh potential benefits. There has been a lack of adherence to screening guidelines throughout the country for prostate cancer and breast cancer, where older patients have been screened in spite of recommendations to the contrary. The national average for older men screened for prostate cancer was 19.5% as of 2012; the national average for older women screened for breast cancer was 24.2%.

Late referral to hospices may affect the quality of care provided, the patient and family experience, and overall satisfaction with the healthcare system. The national average for individuals enrolled in hospice care within 3 days of death was 16.8%.

Patients with dementia may have lessened interest in food, but placing a feeding tube in patients with advanced dementia may introduce more complications with their care and has not been shown to either improve or prolong life. The percentage of patients with advanced dementia who were given a feeding tube was 6% as of 2012.

The report described “unnecessarily aggressive care” near the end of life may detract from rather than improve quality of life for some patients and can lead to higher care costs. The average number of days in an ICU in the last 6 months of life for Medicare beneficiaries ranged from 1-9 days, with a mean of 3.6 days.

Lead author Dr Bynum explained that the improvements made in the US healthcare system have occurred through a variety of mechanisms, from the efforts of clinical providers changing care processes to regulatory changes such as the removal of many high-risk medications.

“Still other changes will be through the efforts of older adults themselves and their families as they become more informed and engaged in the decisions made about their health care, such as how the last days and months of their lives will be lived,” the authors wrote.