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Background. - This study explores the quality improvement potential of reviewing care for long-stay, elderly medicine service patients hospitalized for congestive heart failure, acute myocardial infarction, or pneumonia at a large Midwestern teaching hospital. Methods. - Medical records were reviewed for 120 patients aged 65 years or older who were discharged between January 1987 and June 1989, with hospital stays of 15 days or longer. Patients' severity of illness on admission was rated using the Medicare Mortality Predictor System; process quality of care was rated using a structured implicit review form for judging several dimensions of clinical assessment and decision making. Serious complications were coded by etiology and type and judged as possibly or probably preventable. Logistic regression was used to identify risk factors for iatrogenic events; multiple regression was used to assess potential outcome bias in ratings of overall quality of care. Results. - Of 120 medical records reviewed, 70 (58.3%) suffered at least one iatrogenic complication. Forty-three patients (35.8%) suffered an iatrogenic complication rated as potentially preventable. Significant predictors of all iatrogenic complications were quality ratings of initial physician assessment, patients' inability to walk unassisted, and low Glasgow Coma Score. For potentially preventable complications, quality ratings for physician documentation of functional status were also significant. Ratings for overall quality of care were not significantly influenced by the mere presence of death or complications. Conclusions. - Iatrogenic complications are likely to be an extremely common experience for elderly medicine service patients with long lengths of stay. A significant portion of these complications may be potentially preventable with closer attention to initial assessment and documentation of patients' functional status. (Arch Intern Med 1992;152:2074-2080)

In the 1990s and the future, elderly patients with chronic diseases will be the recipients of a large proportion of the medical services in the United States. Health care professionals and planners, as well as economists, are unable to control the rising costs of medical care. In addition, ethical, medical, and economic issues have prompted a need to analyze the goals of medicine. Some important issues include: the quality and quantity of medical care; the type of persons provided with health care; and the necessity of various medical tests and procedures. Studies show that medical expenses are highest in the last year of a patient's life and are due primarily to the costs of maintaining care for very elderly patients with chronic diseases. In addition, the high medical costs of patients who die constitute a major portion of the age-related rise in Medicare costs. Chronically ill and frail patients often require frequent readmissions to the hospital, physician's visits, and skilled nursing facility care. Health care costs appear to vary with cause of death, with cancer incurring higher costs than heart attack or old age. Various recommendations are made for societal programs that would ensure equitable access to adequate health care. Strategies to improve relations between physicians and elderly patients are also discussed. They include: the use of hospices; care coordination; the development of standards for defining life-sustaining therapy; standards for effective care and use of resources; and improvement of prognostic skills. (Consumer Summary produced by Reliance Medical Information, Inc.)