One of the most important tools in improving geriatric care developed in the last 20 years is the ACOVE framework (Assessing Care Of Vulnerable Elders)--something we’ve written about many times. In this approach, experts and evidence are used to define a floor of quality care below which would constitute bad care for vulnerable elders. ACOVE uses a series of IF . . . THEN . . . BECAUSE . . . statements to specify triggering conditions for a process of care and a rationale for performing the process. For example, IF an older adult has had two or more falls in a year, THEN s/he should have gait and balance assessed BECAUSE therapy or environmental modification can reduce the risk of a fall with injury.

The current ACOVE framework has sixty-five IF. .. THEN statements that can be broken into two major categories: general medical issues that are more common among older adults but not restricted to them, such as hypertension, diabetes, and depression; and geriatric syndromes that are almost entirely limited to older adults, such as dementia, incontinence, and falls. The basic finding has been that even among the vulnerable older adult population (i.e., the 15 to 20 percent of most at risk elders), providers offer about 55 percent of indicated care for general medical conditions, but only 30 percent of indicated care for geriatric conditions. (As an aside, we all recognize that the health care system and particularly primary care providers are pretty overwhelmed even achieving this level of care. Only better constituted and organized health care teams are going to be able to dedicate the time on task needed to improve quality significantly.)

Given the fact that older adults’ well being is MORE dependent upon quality care than younger adults, both numbers are troubling. But two major talks at the recent American Geriatrics Society meeting shed further light on these issues. First, in his Henderson lecture, David Reuben, MD, one of the members of the original ACOVE RAND/UCLA team and a current John A. Hartford Foundation Center of Excellence Director, discussed how quality of care had improved over time for general medical conditions as assessed in 1998, 2002, 2006, and 2007. However, there has been little or no improvement in care of geriatric conditions over that time. To my mind this pattern of differences shows that the changes are not an artifact of reporting or shifting data collection techniques, but rather represent a real distinction. Health care systems have worked hard on issues like diabetes and even depression care and improved their processes.

Unfortunately, even though geriatric syndromes are just as serious, if not more, in their impact on lives and on costs of care, they have not been the center of attention. I would love to see measures like ACOVE used to track the impact of the many educational interventions that have been put in place in geriatrics (e.g., the John A. Hartford Foundation/Association of American Medical Colleges geriatric curriculum grants, the Donald W. Reynolds Foundation Geriatric Training Grants, and the HRSA Geriatric Education Centers. I would also love to see researchers use ACOVE to measure the benefits of Accountable Care Organizations (ACOs) and Medical Homes.

Second, Lillian Min, MD, a 2005 Health Outcomes Scholar and a Center of Excellence Scholar at the University of Michigan (previously at UCLA) added another nuance in her award-winning plenary paper, which looked at the relationship of number of health conditions and ACOVE quality of care measures. A long-time and perplexing finding has been that quality of care measured as percentage of indicated care provided goes up with the number of conditions that an older adult has. Given limited time in office visits combined with increasing complexity, one would expect the opposite. However, by using one of the ACOVE intervention trials in which there was active screening for geriatric conditions, Dr. Min was able to separate the number of general medical conditions from the number of geriatric conditions. She found that the two measures have exactly opposite relationships to quality. The more general medical conditions, the higher the quality of care for general medical conditions (but not for geriatric care quality). Whereas, the more geriatric conditions, the worse the quality of care was for both general medical conditions and geriatric conditions. The general medical conditions seem to offer some positive synergy in the care of other general medical conditions, while the more complex, multifactorial, and murkier geriatric conditions create negative synergy for everything.

My first thought was that this difference may reflect the inability of frail older people to participate effectively in their own care. What all of the geriatric syndromes may share is a loss of reserve and function. What is clear, however, is that there really is something special about caring for people with geriatric conditions that is different from caring for people who have only general medical issues. Somehow, geriatric conditions disrupt the care process and predict lower quality of care. It suggests that getting effective primary care in place for people with things like incontinence, dementia, and falls may be even harder than we thought.