Quality of care for older persons at the dawn of the third millennium

During the past quarter century, researchers, providers, insurers, and governmental agencies have devoted considerable effort to improving and standardizing the quality of health care provided to older persons. Because older persons differ from younger persons as a result of their life expectancy, disease prevalence and comorbidity, social resources, goals of treatment, and preferences for care, defining and measuring quality of care has been more difficult for this age group. Nevertheless, several decades of research have led to reliable, although imperfect, methods of measuring quality, including those for geriatric conditions. Using these measurement approaches, a variety of studies using different patient populations and sampling strategies have consistently identified deficiencies in quality of care provided to older persons. Moreover, efforts to improve quality of care for older persons have been difficult to design, implement, and sustain. Some have been successful, including having effects on outcome measures, but have not made the transition from research to clinical settings. Others have used quality improvement methods to improve the care of diseases (e.g., diabetes mellitus, congestive heart failure) that commonly affect older persons. However, the lack of alignment of incentives between providers and insurers for most older persons is a major barrier to this approach. In addition, there is no concerted effort among providers, regulatory agencies, and insurers to move the quality-of-care agenda for most Medicare recipients. Despite substantial progress in defining and measuring high-quality care for older persons, the goal of ensuring that older persons receiving such care remains a distant hope.