In this secondary analysis of the ACOVE-2 practice-based quality improvement study, we hypothesized that better adherence to evidence-based quality indicators would improve patient-reported outcomes for falls and UI. We found a small but clinically meaningful improvement in incontinence quality-of-life (2.5 points) over ten months in response to a 15% percentage-point quality improvement for UI, a realistic level of improvement in quality that was achieved in the ACOVE-2 practice-based intervention.19
The IQOL response we observed in this analysis corresponds to prior studies of UI patients with a small improvement in global self-reported UI symptoms and half the improvement of those with a substantial decrease in incontinent episode frequency20, 27
We also found a small improvement in falls efficacy (.8-point improvement in the FES) associated with better quality of care for falls, i.e., the 20 percentage-point improvement achieved in the ACOVE-2 study. The response we observed was approximately two-thirds the effect on FES found in an intensive home-based falls-reduction intervention.9
Our results shed further light on our understanding of ambulatory care for geriatric conditions. For both falls and UI, our analysis extends prior interventional research by measuring the full spectrum of office-based care that includes diagnostic processes (history-taking and physical examination) as well as treatment. In this study, our broader practice-based approach was modestly linked with better outcomes, but not as tightly linked as in clinical intervention trials that improved falls efficacy 9, 13, 31, 32
(e.g., pharmacologic or behavioral therapy).
Although the individual QI-level falls scores appeared to be positively related to better FES, the patient-level simple summary score was not. The simple summary score was an inadequate measure of comprehensive falls care because so many individuals in our sample did not receive physical exams. For these patients, gait and balance abnormalities could not be identified and therefore appropriate treatment could not be directed at improving their falls outcomes. Our results suggest that the association between process and patient-level outcomes for falls was restored by scoring with the CPQI, which assigned those without physical exam with an additional penalty for failure to treat. To our knowledge, this is the first report to test an alternative scoring method that addresses serial care measures in which failing to carry out an early care process results in exclusion from eligibility for downstream QIs. The CPQI scoring modification addresses this issue, emphasizing the importance of performing high-quality comprehensive care from screening to diagnosis to treatment to follow-up. These findings concerning falls care demonstrate that patient-level quality measures obfuscate detection of poor comprehensive care and should be avoided in future quality indicator design.
Although the ACOVE-2 intervention improved UI and falls quality of care at two intervention clinical practices,19
there remained substantial room for improvement. The quality of care delivered to individual patients was a better predictor of patient-reported UI- and falls-related outcomes than whether a patient was seen at an intervention versus control practice.
IQOL scores of the UI sample as a whole worsened over the relatively short follow-up interval (10 months), which was inconsistent with other studies that have found better IQOL scores as patients age and adapt to their UI symptoms.20
Rather than improving the quality of life for the sample, it appears that better quality of care attenuated a natural decline that occurred in our sample over 10 months, with only a small subset of patients (i.e., those with better than 75% of indicators passed) experiencing symptom improvement. The decline in IQOL may reflect the advanced age of our sample, which contrasts with prior IQOL studies that focused on younger populations. Some individuals in our older sample may also have thought their symptoms were a normal part of aging at baseline, but developed more concern about symptoms as a result of increased labeling and medical attention.33
A strength of our study design is that we used clinically detailed quality of care data on older outpatients that are not available in administrative datasets. We also administered measures of condition-specific symptom severity before and after the delivery of care. The data were collected prospectively in a community-based sample of older patients with falls and UI symptoms. However, the findings should be viewed in light of the limitations of the ACOVE-2 sample, which was not ethnically diverse and was assembled from only two medical groups. Our results also cannot be generalized to patients who cannot self-report their FES or IQOL. We also did not collect clinical outcomes in the ACOVE-2 study, for example frequency or severity of subsequent falls or number of incontinence episodes. Clinical severity measures would complement patient-reported outcomes in future quality improvement studies.
In conclusion, we found that the quality of care for falls and UI was associated with improvement in falls efficacy and UI-related quality of life. The link between better primary care for these conditions and improved outcomes should provide impetus for strengthening efforts to enhance care of these conditions within primary care practices.