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FORUM - Translating research into quality health care for Veterans

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Defining Better Care for Aging Veterans

VA was among the first health systems to recognize how aging would impact care and costs, and, presciently, it prepared by adopting innovative approaches to research, education, and clinical care. Recently, national policies and customer demand have stimulated new measures focusing on providing care in more home-like settings that better match the needs and values of patients and families.

Those of us who care for older veterans feel passionately about the approaches that VA has adopted. Yet, when we step into our administrative or research personae, questions linger. Who really benefits? What will it cost? Is it sustainable? Could our finite resources be used in better ways? The "market-based" indicators outside VA are discouraging--with the exception of academic settings (where graduate medical education requirements demand minimal exposure to model geriatric care), the numbers of practicing geriatricians have been declining.

For the researcher or administrator seeking to define better care for aging veterans, three principles are key.

First, we must get further into the "black box" of our interventions. VA's care delivery is based on a model of primary care, which has been indisputably effective in improving the quality and coordination of our care. Yet, a dozen years ago, a VA-sponsored multi-site trial showed this intervention increased, rather than reduced, the use of inpatient care. VA did not abandon primary care based on these results, but ongoing work continues to probe deeper to better understand how structures (e.g., makeup of teams) and processes of care (e.g., fidelity to evidence-based practices) determine outcomes.

Models of geriatric care demand similar scrutiny. At one time, home-based primary care and comprehensive geriatric assessment were considered the "magic bullets" of caring for complex older patients--yet trials within VA have shown either modest benefits or substantial costs.1,2

As with primary care, we now must "muddle through," probing with quantitative and qualitative methods to understand what aspects of care make a difference, and which patients benefit. In the absence of an accepted "gold standard," much variation exists across VA in geriatric care. Harnessing that variation for self-inquiry requires that the entire delivery system be engaged in practice-based learning.

Second, complex chronic illness, not aging itself, is the challenge. A century of geriatric bioscience has demonstrated that age is a poor surrogate for physiological function, and that the stronger determinant of quality of life is chronic illness. But there is growing evidence that care focused on only a single disease leads to inadequate attention to other problems, to the patient's detriment. Our knowledge base for managing complex, co-occurring problems is sparse, and demands response from the research community.

New methods of inquiry, such as "real world" trials that do not exclude patients with comorbid illness, and large scale observational studies that tap into electronic health records, are needed to understand such complexity. The physical and psychological effects of combat trauma surely have impact over the lifespan and must be studied—in both older and younger veterans.

Third, meaningful quality measures must be developed and validated. Arguably, the greatest contributor to VA's quality transformation over the past decade has been the systematic use of evidence-based measures of quality. Quality measures have also been used as surrogate outcome measures to test delivery system innovations. Little is known about measuring the quality of care rendered to patients with complex, chronic illness, and concerns have been raised that individual metrics may be inappropriate for frail elderly. Recently, RAND investigators constructed a quality index from 21 process-of-care indicators and showed its association with survival among older managed care patients.3

While the RAND population was not as frail as VA's, and not all measures would be relevant to older veterans, the potential utility of the RAND approach is obvious. The major barrier to executing such an approach, the burden of collecting multi-dimensional indicators, could be substantially mitigated through appropriate use of VA's electronic health record.

  1. Cohen HJ, et al. A Controlled Trial of Inpatient and Outpatient Geriatric Evaluation and Management. New England Journal of Medicine 2002; 346(12):905-12.
  2. Hughes SL, et al. Effectiveness of Team-Managed Home-based Primary Care: a Randomized Multicenter Trial. Journal of the American Medical Association 2000; 284:2877-85.
  3. Higashi T, et al. Quality of Care is Associated with Survival in Vulnerable Older Patients. Annals of Internal Medicine 2005; 143:274-81.

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