Prioritizing Care of Complex Elders using Survival and Functional Status Outcomes

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DESCRIPTION (provided by applicant): Many clinical guidelines for general preventive and chronic diseases have been shown to improve health outcomes in selected populations of older adults. However, it is unclear whether adherence to multiple guidelines for elders with multiple chronic diseases will result in benefits that are comparable to healthier elders. It is also unclear whether care of specific conditions, coordination of care, or general preventive measures should have the most priority. Research on quality of care and outcomes among complex older patients is the first step towards targeting overall quality improvement efforts. The evidence- and expert-based indicators developed by the Assessing the Care of Vulnerable Elders (ACOVE) study cover general/preventive medical care plus disease-specific care for 15 medical and geriatric conditions. The indicators have been used to collect quality-of-care and co-morbidity data by detailed medical record review in the ACOVE-1 and ACOVE-2 studies for over 1000 older patients who had 0 to 9 co-existing chronic conditions. This proposed study first aims to test whether better overall quality scores (measured by adherence to the comprehensive set of indicators) among complex (2-3 co-existing chronic conditions) and highly complex (e4 conditions) elders are associated with survival benefit that is comparable to healthier elders (0-1 conditions). The second aim is to test whether certain types of care (e.g., general/preventive care versus treatment of conditions) can be prioritized according to survival benefit. Last, this proposal aims to perform a systematic analysis of whether any combinations of specific chronic conditions (e.g., having diabetes, hypertension, and dementia) are associated with poorer outcomes. To analyze this research question, 3-year survival data will be collected from the ACOVE-2 cohort and pooled with existing 3-year survival data from the original ACOVE-1 study. Results from this study will shed light on whether adherence to guidelines should be specific to a patients' level of co-morbidity based upon links to better outcomes, and whether certain types of care can be prioritized over others. Such information would also be invaluable to clinicians who make decisions whether or not to adhere to multiple clinical guidelines for their older patients with multiple morbidities, to consider in addition to their patients' specific goals of care, preferences, and prognoses. Relevance to Public Health Older patients who receive better quality of preventive care (e.g., cancer screening) and chronic diseases (e.g., high blood pressure) have better survival. This is a study to explore whether following recommended care for multiple conditions have the same benefit for elders who have many chronic diseases (e.g., diabetes, high blood pressure, and dementia). The results can be used by health care systems to prioritize which guidelines to recommend to their older patients whether they are healthy or are burdened by multiple conditions.