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The implementation of guideline care for older people: outside QOF, outside our thinking?
- Jonathan R Bayly (15 August 2008)
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Performance incentives in primary care and priorities in public health don't encourage better care for conditions of ageing
- David Oliver (19 August 2008)
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Age-proofing needed for indicators of quality of care
- Desmond O'Neill (27 August 2008)
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Jonathan R Bayly, Lecturer in osteoporosis and falls University of Derby, Keddleston Road, Derby, DE22 1GB, UK
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This interesting study by Steel and colleagues (1) keeps alive the debate that one unintended consequence of the current Quality Outcomes Framework (QOF) might be to disenfranchise those, particularly the elderly, suffering from conditions not included at present. Two recent national studies commissioned by the Health Care Commission (2) and the Information Centre (3) have found even more disappointing standards with respect to falls and osteoporosis in over 65 year olds in both secondary and primary care. Fewer than 20% of patients presenting with a non-hip fracture following a fall received documented bone health assessment, densitometry or specific treatment and falls assessments were rarely provided for high risk fallers, including those with a fragility fracture history. One possible explanation for this discrepancy may be the difficulty in translating a check on the implementation of specific guidance in to questions that are intelligible to a lay person. Another might be the under-identification of the high-risk groups. Osteoporosis, uniquely in the list of conditions not incorporated in QOF is of course a silent risk factor until the first fracture. Perhaps most importantly the indicators chosen for osteoporosis and described in the web extra tables do not align well to current evidence-based practice or National Institute for Health and Clinical Excellence (NICE) guidance. Calcium and vitamin D3 alone has not been shown to be effective in reducing fractures in community dwelling older people (4, 5) and specific anti-resorptive bone protective therapies are recommended in the UK on the basis of fracture risk over and above that predicted by a diagnosis of osteoporosis alone. NICE has particularly highlighted the clinical and cost effectiveness of targeting therapies at postmenopausal women with a fragility fracture and osteoporosis and in the absence of a QOF domain, the implantation of NICE guidance or another systematic approach to cover this specific area our patients will continue to suffer preventable hip fractures as nearly half of them will have suffered at least one prior signal fracture (6) which almost certainly will have not been assessed or treated. 1. Steel N, Bachmann M, Maisey S, Shekelle P, Breeze E, Marmot M, et al. Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England. BMJ 2008;337(aug13_2):a957-. 2. Clinical Effectiveness and Evaluation Unit. National Clinical Audit of Falls and Bone Health. London, 2007. 3. Hippisley-Cox J, Bayly J, Potter J, Fenty J, Parker C. Evaluation of standards of care for osteoporosis and falls in primary care: The Health and Social Care Information Centre, 2007. 4. Jackson RD, LaCroix AZ, Gass M, Wallace RB, Robbins J, Lewis CE, et al. Calcium plus Vitamin D Supplementation and the Risk of Fractures. N Engl J Med 2006;354(7):669-83. 5. Porthouse J, Cockayne S, King C, Saxon L, Steele E, Aspray T, et al. Randomised controlled trial of calcium and supplementation with cholecalciferol (vitamin D3) for prevention of fractures in primary care. BMJ 2005;330(7498):1003-. 6. Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA. Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research 2007;461:226-30. Competing interests: J Bayly was the lead author for the QOF submission on osteoporosis. He has received assistance to attend conferences, remuneration for lectures and advisory board contributions for a number of pharmaceutical companies with an interest in bone health. |
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David Oliver, Senior Lecturer, Geriatric Medicine School of Health and Social Care, University of Reading
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Sir The excellent article by Steel et al highlights an important issue. Despite the existence of NIHCE or RCP guidelines, we know from audit that the recognition and care for older people with conditions such as falls, osteoporosis, stroke, urinary incontinence, dementia and delirium is patchy and substandard. The reasons for this are complex and may reflect medical and societal attitudes, values, training and an unwritten hierarchy of priorities, as well as a relative lack of focus on such conditions in public health, or Strategic Health Authority Priorities. However, the influence of the Quality and Outcomes Framework (QOF) in the GP contract cannot be discounted. It has proved a great success in delivering those targets it includes - generally fairly easily measureable ones around preventative medicine and screening. However, not everything can appear in the QOF. And if it isnt in the QOF it doesnt tend to happen! So for instance, urinary incontinence affects 25% of women over 65; 50% of people over 80 fall at least once a year and women have a 50% lifetime risk of osteoporotic fracture, over 1 million people in the UK currently have dementia, yet none of these appear. Clearly such prevalent and debilitating conditions are of major importance to patients, to public health and to issues around access and capacity.Their prevalence is such that they cannot all be managed in secondary care. However, as they primarily affect older people they havent been at the forefront of thinking. More to the point they dont lend themselves to /simplistic "metrics" for measurement and so don't appear as it is to difficult to demonstrate that they are being met. Prescription and rationalisation of medicines in older people is another QOF related issue. Firstly, despite the fact that iatrogenic illness related to polypharmacy accounts for many admissions of older people to hospital, prmary care prescribing in over 65s has increased by 50% over the past three years. Secondly, targets around treatment of say hypertension or heart failure dont take into account the high prevalence of side effects in frail complex older people. Thirdly, although there is ostensibly an annual medication review target in the QOF it is doubtful that this really stimulates meaningful risk benefit analysis and rationalisation of medicines in older people with multiple pathology. In short an entrepeneurial model with a performance framework based on what is easily measureable and prioritising conditions affecting the young and middle aged does nothing to improve the care of the old - who are in fact the principal users of the service Competing interests: Dr Oliver is the national secretary of the British Geriatrics Society |
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Desmond O'Neill, Associate Professor Trinity College Dublin, Dublin 2, Ireland
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Indicators of quality of care, such as those assessed by Steel et al (1) in their helpful paper, are usually influenced by the philosophy of monospecialty care. While this may be of relevance to those aged from 50 to 65, after this age multiple pathologies become more common (2). It is increasingly recognized that such indicators are not sensitive to the interactions of frailty, multiple pathology and multiple medications for this group: for a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, application of relevant clinical practice guidelines would lead to the prescription of 12 medications and a complicated nonpharmacological regimen (3)! Further developmental work with older people and clinical gerontologists is needed to define and refine appropriate indicators of quality of care for older people with multiple illnesses. Helpful preliminary studies have set a challenging agenda, with older people requesting care processes that are patient-centred and individualized which support their unique constellations of problems, shifting priorities and multidimensional decision making (4). A focus on the needs of older people, the processes required to meet them, and outcomes based on quality of life and functional status are likely to represent a more scientific basis for measuring the quality of care of older people (5). 1) Steel N, Bachmann M, Maisey S, Shekelle P, Breeze E, Marmot M, Melzer D. Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England.BMJ 2008;337:a957. 2) Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005; 3:223–8. 3) Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005;294:716 -24. 4) Bayliss EA, Edwards AE, Steiner JF, Main DS. Processes of care desired by elderly patients with multimorbidities. Fam Pract 2008;25:287- 93. 5)Bernabei R, Landi F, Onder G, Liperoti R, Gambassi G. Second and third generation assessment instruments: the birth of standardization in geriatric care.J Gerontol A Biol Sci Med Sci 2008;63:308-13. Competing interests: President-Elect of the European Union Geriatric Medical Society |
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