Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d912 (Published 08 March 2011) Cite this as: BMJ 2011;342:d912All rapid responses
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We would like to challenge one of the conclusions in the study by
Shah et al (1) who state that high use of exception reporting, (43% in
Nursing home residents), may compromise care for vulnerable patient
groups. Their study included people from both residential and nursing
homes. It is important to recognise that the majority of nursing home
residents have very significant levels of disability and nursing need with
high levels of co-morbid illness and frailty (2) . In addition if the
definition of terminal illness is based on a negative answer to the
question "would I be surprised if my patient were to die in the next
twelve months" (3) it is likely that many individuals living in nursing
homes would be classified as being terminally ill. In a recent study of
people with diabetes resident in Nursing Homes in Coventry 43% of
residents were bedbound, had no speech or incoherent speech, were
doubly incontinent or had a catheter in situ, and were unable to feed
themselves or had a PEG or nasogastric tube in situ (4). In this latter
group for example, exception reporting in primary care would be entirely
appropriate and in keeping with the needs of these residents.
The emphasis in this very disabled group with huge nursing needs, most of
whom would be regarded as terminally ill, must surely be on the quality of
any remaining life. The Clinical Indicators in the Quality and Outcomes
Framework (QoF) are largely concerned with interventions that have been
shown to improve the quantity of life in younger fitter populations.
Applying this approach and aiming to achieve these indicators in many
nursing home residents is likely to impair the quality of any remaining
life. We therefore feel that high exclusion rates from QoF in nursing home
populations may, in many circumstances, be the right decision, for the
right reasons, in the right population.
References
1 Shah S, Carey IM, Harris T, DeWilde S, Cook DG Quality of chronic
disease care for older people in care homes and the community in a primary
care pay for performance system: retrospective study BMJ 2011 342d912
2 Bowman C, Whistler J, Ellerby M A national census of care home residents
Age and Ageing 2004 33: 561-566
3 Murray SA, Boyd K, Sheikh A. Palliative Care in chronic illness BMJ
2005 330:611-612
4 Gadsby R, Barker P, Sinclair A People living with diabetes resident in
nursing homes - assessing levels of disability and nursing needs Diabetic
Medicine 2011 (in press)
Dr Roger Gadsby GP & Associate Clinical Professor, Warwick
Medical School
Professor Alan Sinclair, Professor of Medicine, and Director of IDOP,
University of Bedfordshire
Competing interests: No competing interests
Dear Sir,
The deficit in the care of chronic medical conditions in different
contexts highlighted by Shah et al is timely and likely to reflect a
burgeoning problem given the rapidly increasing number of nursing home
residents and the ever increasing burden chronic disease in this group as
they continue to live longer.
We note their use of community residents as a comparator group and
the subsequent conclusion that nursing home residents are more likely to
suffer from poorer care as measured by Quality Indicator attainment. We
feel that a more robust comparison between community and residential care
could have been made by controlling this study for performance status,
comorbidity or other markers of frailty, though we accept that this may
have been beyond the scope of their methodology.
The very frail elderly who remain dwelling in the community are a
subgroup who most typify the inverse care law, particularly within the
context of a pay for performance system. Without the protection afforded
by being clustered in residential institutions mitigating some of the
obstacles to effective chronic disease management by family practices, it
is possible that the community-dwelling frail elderly may be less likely
to attain quality indicators and have a higher rate of exception reporting
even than those in residential care.
Nevertheless, the onus may begin to lie on residential institutions
to implement a system of clinical governance incorporating appropriate
monitoring in association with their family practice which would serve to
ensure that quality standards are being attained.
Competing interests: No competing interests
This article notes an increase in rate of QOF exemptions in Care
Homes. This is to be expected and possibly encouraged.
Care Homes contain a higher proportion of adults for whom attention
to chronic disease targets [eg Blood Pressure, HbA1c] should take a lower
priority.
All these targets take time [often years] to show a significant effect in
even fairly large populations. It is vital that the magnitude of effect to
the individual is recognised.
Due to the higher proportion of physiologically frail adults in care
homes v the general population it would be expected that a higher
proportion would be at a stage where the burden and risk of often multiple
medication [due to attention to chronic disease targets] is outweighed by
the low prospect of showing a tangible difference in outcome for that
individual adult in there remaining life span and the increased risk of
them suffering a side effect of that treatment strategy.
The final conclusion of the article that states that QOF should
'consider measures that deal with the specific needs of older people' The
term should perhaps be 'physiologically frail' rather than old. Age in
itself is not a useful marker as we can have many very old but very fit
individuals for whom years of healthy life are expected (and hence plenty
of time to acrue benefit from chronic disease management) and many less
old very 'frail' individuals for whom each day is physiological struggle
and other priorities should be targeted.
Quality targets need to begin to grasp the nettle of dealing with the
realities of frailty and reinforce that the primary targets should reflect
the day to day needs of the very frail [Adequate nutrition,dignified
personal care, social interaction and holistic planning for end of life].
It is not unreasonable to suggest that attention to chronic disease
targets can act against more important priorities. For example in the case
of the frail adult who is faced with 13 tablets with their breakfast where
less tablets may well mean more breakfast. [And realistically more time
for a carer to help with that breakfast.]
Articles such as this that gently suggest a link between rates of
exemption reporting and quality of care risk penalising those who are
holistically balancing the needs of an individual against more easily
measurable targets.
Competing interests: No competing interests
Judging quality of care in older people in care homes
This study of GP's achievement of QOF targets for older people in
care homes asked the question whether these patients received poorer
quality care for chronic disease than comparative patients in the
community. Clearly it would be difficult to achieve comparability of these
two groups and the authors mention this- there are many factors other than
age, sex and degree of dementia which might influence quality of life, and
hence the appropriateness of striving for QOF targets in this group.
However my main concern was that it seemed to be taken for granted that
good quality care in this, by definition, very elderly and debilitated
group was equated with reaching QOF targets.
The data on which these targets are based has very little evidence of
any benefit in people of this age and state of health. In fact the
achievement of tight glycaemic control is shown to increase mortality, and
many very elderly people's lives are made unnecessarily miserable due to
dizziness from postural hypotension or muscle pain from statins. A more
balanced conclusion might be that GP's may or may not be giving
appropriate care in this group, but the achievement of QOF targets is not
the best measure of this.Clearly, monitoring of hypothyroidism and control
of blood pressure in stroke patients are appropriate , and there was
little difference in these parameters compared to community controls, but
tight cholesterol and BP control might well be inappropriate and to
exclude them from these targets would actually be good quality care.
In the majority of very elderly care home residents a much more
pressing concern for the patient is adequate pain relief, management of
bladder and bowel problems, and encouragement to lead as full a life as
they are able.
Competing interests: No competing interests