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Invited Commentary
October 25, 2010

Improving Primary Care for Older Patients: Challenge for the Aging CenturyComment on “Practice Redesign to Improve Care for Falls and Urinary Incontinence”

Author Affiliations

Author Affiliation: Division of Geriatrics, University of California, San Francisco.

Arch Intern Med. 2010;170(19):1772-1773. doi:10.1001/archinternmed.2010.389

We have entered the aging century. The global population older than 65 years will double by 2040, with the most rapid increase among people older than 80 years.1 The aging of populations will challenge health care systems around the world: not only will greater numbers of people have chronic diseases, such as heart failure or cancer, but also many will develop disabling geriatric conditions, such as dementia, difficulty walking, falling, or incontinence. Geriatric conditions are underdiagnosed, and their treatment requires expertise beyond a prescription or surgery. These complex conditions diminish the length and quality of life and the ability of individuals to engage in society.2

Unfortunately, the US health care system often fails to provide recommended care, especially for geriatric conditions. Roughly half of recommended care is provided for general medical conditions among younger and older adults, and less than one-third of recommended care has been provided for geriatric syndromes.3,4 Although systematic efforts have increased the amount of recommended care provided to older adults, these improvements have been small.5

How can we, as physicians, improve care beyond doing our usual best for our next patient? We believe that robust efforts to improve care can be built on the principle that “quality problems exist not because of a failure of goodwill, knowledge, effort, or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized”6(p25)—shortcomings that can be overcome only through redesign of our health care provision systems. For us physicians, it is tempting to say that a redesign of the system of health care provision is too big for my colleagues and me to take on. In fact, the opposite is true: successful redesign often begins small, with changes in the microsystems in which we work, namely, our practices, hospital wards, and operating departments. Microsystems redesigned by health care professionals have improved care and outcomes for older patients in acute care hospitals and in the community.7,8

In this issue of the Archives, Wenger and colleagues report that a novel, pragmatic restructuring of primary care practices improved the care of individuals who had urinary incontinence, had fallen, or were afraid of falling. The intervention, called Assessing Care of Vulnerable Elders Practice Redesign for Improved Medical Care for Elders (ACOVEprime), has 5 key components that 5 primary care practices adapted to their infrastructure, staff, and preferences: (1) case finding via pre–clinic visit screening of all patients 75 years or older, (2) structured visit notes for each condition, (3) medical record prompts for diagnosis and treatment, (4) patient and family educational materials, and (5) physician decision support and staff education. ACOVEprime was evaluated in these primary care practices, each with 6 to 15 physicians, from across the country. In each practice, some physicians participated in ACOVEprime and some did not; the authors do not specify how physicians were allocated to these 2 groups. Each practice screened all patients 75 years or older for a history of a fall, fear of falling, or urinary incontinence before each visit and provided that information to the physician, whether or not the physician participated in ACOVEprime. A total of 56.8% of recommended care for falls and urinary incontinence was provided to patients of physicians who participated in ACOVEprime compared with 35.7% of recommended care for patients who also were screened for the conditions but whose physicians did not participate in ACOVEprime. Thus, ACOVEprime achieved the same level of recommended care for these 2 geriatric conditions as is provided for conventional chronic conditions, such as diabetes mellitus and heart failure. Physicians in ACOVEprime performed many specific recommended practices more often than other physicians: They more often prescribed exercise, tried to discontinue use of benzodiazepines, determined postvoid residuals, and used behavioral treatment for incontinence. Only 1 practice used an electronic medical record, and this site provided substantially more recommended care, independent of the effect of ACOVEprime.

ACOVEprime is notable not only for its effect on recommended care but also for its acceptability to each practice and its efficiency. To improve on previous efforts to increase recommended care for geriatric syndromes,9 ACOVEprime incorporated the following: physician self-evaluation and reflection, collaborative support, participation in a Web-based quality improvement program, and a reward for participation (credit from the American Board of Internal Medicine for Maintenance of Certification).

Health care professionals may ask, “Are there unintended consequences of ACOVEprime?” and “Does it divert attention from management of other conditions or patient concerns?” These questions merit further study. Given the importance of diminishing embarrassing or uncomfortable episodes of urinary incontinence and reducing falls that may result in a broken hip or other serious injury, the benefits likely outweigh any unintended harms.

With our current knowledge of ACOVE-based practice improvement, what further steps are required to apply this knowledge to practice and to the systematic redesign of our health care system? First, the effects of ACOVE-based interventions on patient outcomes, such as falls, injuries, incontinence, and quality of life, should be determined. If interventions that increase recommended care do not improve patient outcomes and health, then we need better recommendations for care. Second, learning the costs of ACOVE-based interventions and their effects on other aspects of primary care will inform efforts to integrate them in practices. Third, we need to learn how to increase performance of recommended care to 100%, not just 50% to 60%. Finally, it will be valuable to learn whether ACOVEprime is sustained over time by the 5 practices and how it can be disseminated to other practices beyond those of the pioneers.

Even with the passage of health system reform legislation, the structure and function of our health care provision system likely will evolve slowly. Small practices will continue to serve a significant proportion of our older adults and most will not have a geriatrician on hand. The burden of geriatric conditions on older adults' well-being and on our communities is substantial and demands the same attention to care improvement measures that nongeriatric diseases, such as diabetes, have received. The availability of ACOVEprime, an efficient, effective, and feasible intervention, advances our ability to provide optimal care to older adults. It is precisely this level of creative redesign of our health care system that narrows the chasm between what we do and what we need to do to care for our older patients.

Correspondence: Dr Landefeld, Division of Geriatrics, University of California, San Francisco, 3333 California St, Ste 380, San Francisco, CA 94118 (sethl@medicine.ucsf.edu).

Financial Disclosure: None reported.

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