Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in EnglandBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a957 (Published 14 August 2008) Cite this as: BMJ 2008;337:a957
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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
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) 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
4) Bayliss EA, Edwards AE, Steiner JF, Main DS. Processes of care
desired by elderly patients with multimorbidities. Fam Pract 2008;25:287-
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.
President-Elect of the European Union Geriatric Medical Society
Competing interests: No competing interests
Performance incentives in primary care and priorities in public health don't encourage better care for conditions of ageing
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.
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.
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
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
Dr Oliver is the national secretary of the British Geriatrics Society
Competing interests: No competing interests
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
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
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.
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.
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.
Competing interests: No competing interests