Primary care

Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study

Tom Fahey, professor of primary care medicine, ^a Alan A Montgomery, lecturer in primary care health services research, ^b James Barnes, registrar, ^c Jo Protheroe, MRC training fellow in health services research. ^d

^a Tayside Centre for General Practice, University of Dundee, Dundee DD2 4AD, ^b Division of Primary Health Care, University of Bristol, Bristol BS6 6JL, ^c Bradgate Surgery, Bristol BS10 6SP, ^d National Primary Care Research and Development Centre, University of Manchester, Manchester M13 6PL

Correspondence to: T Fahey
t.p.fahey{at}dundee.ac.uk

Objectives: To assess the quality of care given to elderly people and compare the care given to residents in nursing homes with those living in their own homes.
Design: Controlled observational study.
Setting: Primary care, Bristol.
Subjects: Elderly individuals (aged 65 years) registered with three general practices, of whom 172 were residents in nursing homes (cases) and 526 lived at home (matched controls).
Main outcome measures: The quality of clinical care given to patients was measured against explicit standards. Quality indicators were derived from national sources and agreed with participating general practitioners.
Results: The overall standard of care was inadequate when judged against the quality indicators, irrespective of where patients lived. The overall prescribing of beneficial drugs for some conditions was deficientfor example, only 38% (11/29) (95% confidence interval 20% to 58%) of patients were prescribed  blockers after myocardial infarction. The proportion of patients with heart disease or diabetes who had had their blood pressure measured in the past two years (heart disease) or past year (diabetes) was lower among those living in nursing homes: for heart disease, 74% (17/23) v 96% (122/127) (adjusted odds ratio 0.18, 0.04 to 0.75); for diabetes, 62% (8/13) v 96% (50/52) (adjusted odds ratio 0.05, 0.01 to 0.38). In terms of potentially harmful prescribing, significantly more patients in nursing homes were prescribed neuroleptic medication (28% (49/172) v 11% (56/526) (3.82, 2.37 to 6.17)) and laxatives (39% (67/172) v 16% (85/526) (2.79, 1.79 to 4.36)). Nursing home residents were less likely to have the appropriate diagnostic Read code linked to their prescribed neuroleptic drug (0.22, 0.07 to 0.71).
Conclusions: The quality of medical care that elderly patients receive in one UK city, particularly those in nursing homes, is inadequate. We suggest that better coordinated care for these patients would avoid the problems of overuse of unnecessary or harmful drugs, underuse of beneficial drugs, and poor monitoring of chronic disease.

What is already known on this topic Doctors too often prescribe harmful drugs and too seldom prescribe beneficial drugs for elderly people The quality of medical care for those living in nursing and residential homes has also been questioned What this study adds Elderly people in one UK city receive inadequate care when judged against explicit quality indicators Those living in nursing homes receive poorer care than those living at home in terms of underuse of beneficial drugs, poor monitoring of chronic disease, and overuse of inappropriate or unnecessary drugs