From May 2004 through June 2007, 6392 elderly patients were first-time admittees to the general medicine inpatient service at the University of Chicago Medical Center (). Of the 5278 (82.6%) who stayed in the hospital more than 1 day, 3359 (63.6%) consented to participate in the study. 1766 (52.6%) of the consenting patients were identified as vulnerable elders through administration of the VES-13, of whom 46 (2.6%) died in the hospital, 65 (3.7%) were discharged to hospice or comfort care, 68 (3.9%) were transferred from an ICU. Another 195 (11%) of patients died before the one month follow-up interview. Of the remaining 1383 patients eligible for follow-up, 898 (64.9%) of patients completed the telephone follow-up interview.
Patient recruitment to and exclusion from study.
Patient characteristics are described in . The 898 patients with complete functional status data were predominantly African American and female with a mean age of 79.3 years (SD 8.2). The mean VES-13 score was 5.6 (SD 2.0), with mean length of hospital stay 5.2 (SD 4.5) days. At the time of admission, 161 (17.9%) patients had impaired cognitive status and 565 (62.9%) of patients reported impairments in at least one Activity of Daily Living (ADL). Patients who successfully completed follow-up were more likely to be be African-American (71% vs. 63%, p=0.012), with a shorter length of stay (5.3 days vs. 6.7 days, p=0.007), lower VES score (5.6 vs. 5.9, p=0.005), trigger fewer quality indicators (7.9 indicators vs. 8.4 indicators, p<0.001, but have a higher Charlson score (1.9 vs. 1.7, p=0.03). There was no difference in adherence to quality indicators or composite quality score between those patients that completed follow-up and those that did not.
Demographics of Study Sample (n = 898)
For those ACOVE POC-QIs that were universally applicable, or not triggered by a specific condition (formal assessment of cognitive status within 24 hours, assessment of functional status, efforts to improve mobility, discharge planning, documentation of nutritional status and assessment of pain within 24 hours), percent adherence ranged from 6.3% to 97.5%, with a mean adherence of 57.9%. () The average number of POC-QIs triggered per patient was 8.0 (SD 1.8). For the 417 patients that triggered between 5 to 7 indicators, mean quality score was 53.1 (50.8 - 55.4). For the 387 patients that triggered between 8 to 10 indicators, mean quality score was 64.4 (63.0 -65.9). 94 patients triggered more than 10 indicators and had a mean quality score of 62.4 (60.0-64.7). There was a positive relationship between number of quality indicators triggered and overall quality score (r=0.33, P<0.001).
Adherence to Universally Applied ACOVE Quality Indicators (n = 898)
400 (44.5%) patients reported functional decline in any of the four time periods. For the time period from admission to discharge, 290 (32.9%) patients reported functional decline. The same fraction of patients reported decline from admission to one month after discharge. When using one month before admission as the baseline, slightly greater numbers of patients reported functional decline [319 (35.5%) from one month before admission to one month after discharge; 329 (36.6%) from one month before admission to discharge]. Patient reports of catastrophic functional decline followed similar patterns during the four time periods, with 197 (21.9%) patients reporting catastrophic functional decline in any of the four time periods. 120 (13.3%) reported catastrophic decline from admission to discharge, and 127 (14.1%) reported catastrophic decline from admission to one month after discharge. The number of patients reporting catastrophic decline was similar [143 (15.9%)] for both one month before admission to discharge and 147 (16.4%) one month before admission to one month after discharge. (, http://links.lww.com/A1255
In multivariate logistic regression testing the effect of overall quality score on functional decline, there was no observable relationship in any of the four time periods. Examining the relationship between covariates [VES-13 score, baseline ADL limitations, number of QIs triggered, Charlson index (measure of comorbidity burden), and interaction between VES-13 score and quality score] confirmed the importance of controlling for these factors in examining the relationship between quality and outcomes. As predicted, patients that were more frail (higher VES-13 score), with more comorbidities (higher Charlson index), more geriatric conditions (triggered more quality indicators), but with preserved physical function (fewer ADL limitations at baseline) were significantly more likely to suffer functional decline between one month before admission and one month after discharge. These relationships were consistent for all four time periods of functional decline ().
Relationship between Overall Quality Score and Functional Decline (n = 898)
To examine the effect of individual quality indicators, analysis was focused on functional decline during the time period from one month before admission to one month after discharge, the time period which is likely most affected by in-hospital processes. In this analysis, patients who had a documented effort to improve mobility (i.e. order for physical therapy) were more likely to experience functional decline (OR 1.5, 95% CI 1.1-2.0, p=0.017) and catastrophic functional decline (OR 1.9, 95% CI 1.2-3.1, p=0.010). In contrast, patients who received documentation of nutritional status were less likely to experience functional decline (OR 0.4, 95% CI 0.2-0.6, p<0.001) and catastrophic functional decline (OR 0.3, 95% CI 0.1-0.6, p=0.001). Of note, these findings were consistent across all time periods.
Because there is the possibility of confounding due to patient illness (sicker patients that are more likely to experience functional decline may be more or less likely to receive certain care processes), the association between illness covariates (Charlson score, VES-13 score, number of baseline ADL limitations, length of stay, code status and the number of quality indicators triggered) and adherence to quality indicators was also examined. Patients that received above median quality score were more likely to have a longer length of stay (5.6 days vs. 4.9 days, p=0.009) and trigger more quality indicators (8.2 indicators vs. 7.7 indicators, p<0.001). With respect to individual quality indicators, patients who had a higher VE score (OR 1.1 95% CI 1.0- 1.2; p=0.018) who triggered more quality indicators (OR 1.35, 95% CI 1.2-1.5, p<0.001), and had a longer length of stay (OR 2.2, 95% CI 1.7-2.9, p<0.001) had a significantly greater likelihood of having a mobility plan. Patients who triggered more quality indicators were 22.7 (95% CI 6.7 -76.8, p<0.001) times more likely to have a nutritional status assessment.