Improving the Health and Health Care of Older Americans
A Report of the AHRQ Task Force on Aging
In this report, the Task Force on Aging provides a rationale for the Agency for Healthcare Research and quality (AHRQ) to develop, implement, and disseminate an agenda on health services research related to aging. The report recommends that AHRQ expand and sharpen its focus on aging issues in several specific areas.
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The free print version of this report is available at the AHRQ Publications Clearinghouse while supplies last (Publication No. 01-0030). Call toll free 1-800-358-9295 or E-mail the Clearinghouse at AHRQPubs@ahrq.hhs.gov.
By Arlene Bierman, M.D., M.S., COER; William Spector, Ph.D., CODS (Co-Chairs); David Atkins, M.D., M.P.H, CPTA; Jayasree Basu, Ph.D., CPCR; Carolyn Clancy, M.D., COER; Marcy Gross, Women's Health Coordinator; Anne Lebbon, IOD; Linda Moody, Ph.D., CPCR; Jeffrey Rhoades, Ph.D., CCFS; Debbie Rothstein, Ph.D., ORREP; Judy Sangl, Sc.D., CQuIPS; Barbara Schone, Ph.D., CCFS; Christine Williams, M.Ed., OHCI
Aging-Related Health Services Research: The Rationale
Delivering Health Care to an Aging Population
Providing and Financing Health Care Servicers for Older People
Using Aging-Related Health Sercvices Research to Answer Key Questions
Filling in Gaps in the Knowledge Base
The Role of AHRQ in Supporting Aging-Related Health Services Research
Building a Research Agenda
Improving Clinical Practice, Health Care Organization, and Delivery
Aligning Incentives to Promote Efficiency, Access, and Quality
Improving Access to Care and Reducing Health Disparities
Building a Research Infrastructure
Responding to Data Needs
Training Health Services Researchers
Task Force Recommendations for Agency Action
Appendix A. Recent Aging-Related Grants in AHRQ's Portfolio
Appendix B. AHRQ's Aging-Related Training Support
Appendix C. Selected Aging-Related Projects Recently Implemented by AHRQ that
Address Task Force Recommendations
The Task Force on Aging, composed of staff within the Agency for Healthcare Research and Quality (AHRQ), was appointed to give the Agency advice and recommendations on aging-related issues in which AHRQ could play a leadership role in health services research. This Task Force assessed AHRQ's research portfolio and held extensive discussions with other Federal agencies and private organizations that support aging-related research. The findings and recommendations that grew out of the Task Force efforts in 1999 form the basis of this report.
Since that time, AHRQ has used the report of the Task Force on Aging as a foundation to enhance its efforts in aging-related health services research. Some of these efforts are listed below; additional information appears in an appendix to this report.
- Focusing on the elderly as a priority population. AHRQ's reauthorization in December 1999 specifically designated the elderly as a priority population for health services research. In June 2000, AHRQ published a new Health Services Research Program Announcement, specifically stating its interest in research proposals that address critical questions related to enhancing health care delivery for the elderly by improving health and functional outcomes and reducing health care disparities among older persons.
Building the foundation for making aging health services research a long-term priority in AHRQ's research initiatives. AHRQ has worked to integrate a focus on aging issues into its on going programmatic activities. For example, AHRQ's recent Request for Applications on "Building Research Infrastructure and Capacity" specifies improving care at the end of life as a topic of research interest and includes older people as a priority population. AHRQ's program of Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED), which was initiated in September 2000, includes one center that will investigate health issues of importance to Native American elders.
Important issues in the care of older persons are being addressed within AHRQ's Evidence-based Practice Center (EPC) program. Several EPC reports on topics relevant to the health of older people have been recently published or are in process. These include anesthesia management during cataract surgery, use of physician services by the Medicare population, and management of coexisting cataract and glaucoma. AHRQ is also working with the Health Care Financing Administration, National Center for Health Statistics, and Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services to coordinate, develop, and implement a research and data plan on long term care.
- Promoting AHRQ's initiatives and activities related to research on aging. AHRQ's Internet site now has a section devoted to "Elderly Health Care." Visitors to the site can easily locate the most recent research findings from AHRQ-supported research on issues related to the health and long-term care of older Americans.
- Developing, with other stakeholders, an agenda for aging research. AHRQ is engaged in ongoing dialog with other Federal agencies, foundations, and not-for-profit organizations in a continuing effort to further the science base for research in this field. As part of this process, AHRQ has held three expert meetings since October 1999. The first focused on identifying research questions and data needs for residential long-term care; similar priority issues for community-based long-term care were examined at the second meeting, held in June 2000. In October 2000, AHRQ convened a third meeting of experts in aging issues to inform the development of future research initiatives for improving functional outcomes in older people; cosponsors included the Health Care Financing Administration, the National Institute on Aging, and the John Hartford Foundation.
AHRQ continues to examine its intramural and extramural programs to identify research opportunities for addressing key questions specific to the health care needs of older people. AHRQ is committed to exercising leadership in conducting and supporting research that leads to improvements in health and quality health care for the Nation's older population. I am grateful to the Task Force on Aging for its contributions toward achieving this goal.
John M. Eisenberg, M.D.
Agency for Healthcare Research and Quality
As we enter the new millennium, the Nation is confronted with the enormous challenge of preparing to meet the demands of an aging society. In the face of current demographic trends, increasing health care costs, and concerns about the quality of health care, the financing and delivery of care for older people is a critical health care policy challenge. Health services research is needed to assure that older people do indeed benefit from recent advances in biomedical, clinical, and behavioral and social science research with respect to a host of aging- related issues.
Since its inception, AHRQ (formerly the Agency for Health Care Policy and Research), has engaged in, supported, and disseminated aging-specific health services research. However, prior efforts have not been coordinated. In January 1999, AHRQ's Director, John Eisenberg, M.D., established the Task Force on Aging to make recommendations regarding the appropriate role of the Agency in aging-related health services research and to recommend areas where AHRQ should play a leadership role.
Early in the Task Force's discussions, we decided to focus our efforts on cost-effective interventions that enhance functioning and health-related quality of life (HRQOL) or prevent functional decline. With this decision, we focused on gaps in knowledge that influence the ability of health care services to improve functioning and HRQOL including costs, financing, barriers to access, organization and delivery of care, and clinical practice, as well as the interaction of these factors with individual patient characteristics and preferences, family, and community. Figure 1 (27 KB) describes the conceptual framework we used. It includes a patient-centered rather than disease-specific focus. This framework also recognizes the role of health policy in influencing patient outcomes. All of the arrows on our framework are bidirectional, recognizing the multiple, complex interrelationships that influence health and function in older people.
A focused research effort to determine how the health care system can most cost-effectively prevent disability, reduce functional decline, and extend active life expectancy in older people can provide decisionmakers with the information needed to accelerate the decline in age-specific disability rates and to allocate limited resources efficiently. This report summarizes the findings and recommendations of the Task Force and provides a rationale for developing an agenda on health services research related to aging.
Aging-Related Health Services Research: The Rationale
Delivering Health Care to an Aging Population
An aging population, together with rising health care costs and rapid health system change, presents a major challenge in the delivery of health care to older Americans.
The changing composition of the population is already putting increasing pressure on the health care system. In 2011, 77 million baby boomers will begin to turn 65, and by 2025, the number of Medicare beneficiaries is expected to reach 69.3 million, representing 20.6 percent of the U.S. population, with the "old old"—those over age 80—comprising the fastest growing segment of the population. Along with the increased numbers of older Americans, the elder population is becoming increasingly diverse; it is expected that by the year 2030, one in four people over the age of 65 will be from a racial or ethnic minority. Moreover, there is also concern that changes in fertility, women's labor force participation, and increases in the divorce rate may reduce the ability of families to take care of older family members who have disabilities, placing even greater demands on public and social programs.
Because of these demographic trends, there is concern that health care costs for the elderly population will continue to grow dramatically. Per capita expenditures for elderly living in the community were more than three times those of the nonelderly in 1996—$5,644 vs.$1,8651—and are projected to increase to $7,674 (in 1996 dollars) by 2005.2 Medicare and Medicaid long-term care expenditures are also projected to double by 2005.3 These projected increases in taxpayer-funded costs will place great pressure on these programs to reduce costs. Consequently, there is apprehension that continuing and rising pressures to contain costs will adversely affect health care quality and access.
Furthermore, the rapid changes in the health care system that have already occurred have had significant effects on the care provided to elderly people. For example, previous efforts to control costs have resulted in an increase in Medicare managed care, market instability, and shifting of care to ambulatory settings. There have also been significant changes in the provision and financing of long-term care, with growing use of community-based long-term care such as home care and assisted living communities. The role of institutions has also changed, with nursing homes being used more extensively for subacute care. Nursing homes are confronting many other changes, such as capitation and prospective payment for skilled nursing home care and quality measurement and reporting. There are many unanswered questions about the effect of these changes on quality and cost.
Providing and Financing Health Care Services for Older People
The unique challenges in providing and financing health care services for older people require a targeted research focus.
Caring for older people involves clinical complexities that are difficult to coordinate at the health system level and because of fragmented financing, are also difficult to manage financially. Aging results in both pathophysiologic and pharmacokinetic changes that must be addressed in clinical practice. Comorbidity is common, presenting a challenge to clinical management. End-of-life decisionmaking grows in importance, focusing attention on quality of life. Family members often play an important role in providing and managing care, and require education, support, and assistance in these tasks.
Nevertheless, the majority of older people remain active and independent and the prevention of disability among this group of elders is critical. Effective and efficient care for older people therefore requires new models of coordination among preventive, acute, chronic, rehabilitative, and long-term care services. Furthermore, financing of care to older people is fragmented and improved models of care will depend on appropriate payment models.
Improving the quality of care for older people is likely to have a substantial impact on their functional status and therefore their quality of life. The underuse of effective interventions, the overuse of interventions shown to be ineffective, and the misuse of others (especially polypharmacy) have all been well documented in the elderly. Many doctors do not routinely assess the functional status of their older patients, nor do they have the knowledge and skills requisite for geriatric practice. Quality measures are needed to assess the effectiveness of interventions to improve care in these areas.
While the unique constellation of issues confronting the elderly described here necessitates a targeted focus on older people, aging-related research shares common issues with research on improving care for the chronically ill and disabled; so there is a need to coordinate and collaborate across research in all three of these areas.
Using Aging-Related Health Services Research to Answer Key Questions
Aging-related health services research can provide answers to key questions about outcomes and effectiveness; cost, use, and access; and quality measurement and improvement for older people.
The issues addressed in general health services research (e.g., optimal treatment, access to care, and the organization of care) need to be addressed specifically with respect to the health needs of older people. Health services research is uniquely able to address the multiple factors that impact upon health outcomes in the elderly such as comorbidity, patient beliefs, values and preferences, social support, and multiple sites and settings of care, as well as finance and policy factors. Health services research is multidisciplinary and conducted collaboratively by clinicians, nurses, and social scientists. Distinctive features of this research are its patient-centered focus and emphasis on studies related to maximizing function and health-related quality of life. The "basic sciences" of health services research are essential to this endeavor: outcomes and effectiveness research, cost-effectiveness analysis, decision analysis, health status measurement, quality measurement and improvement, and health economics.
Filling Gaps in the Knowledge Base
Enormous gaps exist in the knowledge base with respect to how to best organize, finance, and deliver care for older people.
Enormous gaps exist in our knowledge of what works with respect to:
- The organization, financing, and delivery of health care services to achieve measurable improvement in the health-related quality of life of older people.
- The most cost-effective ways of achieving these improvements.
- How to implement existing knowledge of what improves function in clinical practice.
During the 1990s, two committees of the Institute of Medicine recommended a concerted research effort supported by a substantial financial commitment to address these gaps. The first report4, which was published in 1991, defined the complementary roles of basic biomedical research, clinical research, behavioral and social science research, health services delivery research, and research in biomedical ethics. The committee recognized both health services research and the role of AHRQ in supporting this research as an integral part of this agenda.
The report5 from the second committee, which was chaired by present AHRQ Director John M. Eisenberg, further defined the role of health outcomes and health services research in providing the critical information needed to improve the health and function of older people. Cognizant of research advances since the publication of that report in 1996, as well as changes in the health care environment, this Task Force report builds upon priority areas identified.
The Role of AHRQ in Supporting Aging-Related Health Services Research
To help identify an aging research agenda in which AHRQ could make unique contributions, the Task Force held an initial set of discussions with other Federal agencies within the Department of Health and Human Services (HHS), with the Department of Veterans Affairs (VA), and with private organizations and foundations that have an interest in aging issues to discuss potential areas for future collaboration.
The HHS agencies include:
- The Health Care Financing Administration (HCFA).
- National Institute of Aging (NIA).
- Administration on Aging (AoA).
- The Office of Disability, Aging, and Long-term Care Policy (DALTCP) within the Office of the Assistant Secretary for Planning and Evaluation (ASPE).
Private organizations contacted include:
- The American Association for Retired Persons (AARP).
- Hartford Foundation.
- Arthritis Foundation.
- Robert Wood Johnson Foundation.
- The Commonwealth Fund.
In light of this dialogue, the Task Force concluded that the Agency's mandate to study quality and outcomes uniquely positions AHRQ to provide answers to basic questions about health care for older people. AHRQ is the primary Federal agency that supports research on the health care system by focusing on the relationships among health policy, the organization and financing of health care services, clinical practice, patient preferences, and health outcomes. As a result, AHRQ can make a significant contribution to the field of aging health services research by supporting work designed to answer basic questions about health care for older people.
By funding work that reveals the most effective approaches and by assuring that these findings are ultimately put into practice, AHRQ will be contributing to its three strategic goals:
- To support improvements in health outcomes.
- To strengthen quality measurement and improvement.
- To identify strategies to improve access, foster appropriate use, and reduce unnecessary expenditures.
The Task Force believes that there are many other compelling reasons why AHRQ can and should assume a leadership position in this area:
- AHRQ does not manage any health programs and is not a regulatory agency, it can address the entire health care system without programmatic conflicts of interest.
- Research on the cost-effectiveness of care for the elderly is necessary to inform ongoing health care debates that result in changes in health benefits and financing mechanisms for the elderly. No other agency is filling this void.
- The Agency's agenda includes all populations—from active people who are independent but who are beginning to use the health system more frequently to disabled people who are dependent in daily activities—and all settings of care, including hospitals, community care, assisted living, nursing homes, and care provided by family and friends.
- AHRQ already has considerable experience and expertise in health services research related to aging. The Federal Government, as a principal payer for care for the elderly through Medicare and Medicaid, has a major stake in finding answers to policy questions that affect the quality and cost of care for older people. AHRQ-supported research can help provide those answers.
Building a Research Agenda
The Task Force recommends that the Agency focus its aging health services research agenda directly on answering the overarching question: "What are the most effective and efficient means to provide health care to older people so that the end result is a measurable improvement of the health of this population?" The Task Force has identified three key areas of focus to help provide the requisite knowledge to improve the health and functioning of older Americans. It is necessary to:
- Improve clinical practice, health care organization, and delivery.
- Align financial incentives and benefit decisions with desired outcomes.
- Improve access to care and reduce health disparities.
Beyond improvement in knowledge it will also be necessary to translate this knowledge into practice. The three key research areas described below are designed to move us toward achieving this objective.
Improving Clinical Practice, Health Care Organization, and Delivery
We need to understand how best to improve and integrate preventive, acute, chronic, rehabilitative, and long-term care for the purpose of reducing illness burden and improving health-related quality of life. Overarching research issues that need to be addressed in this area include:
- Developing cost-effective models of acute, preventive, chronic, rehabilitative, and long-term care delivery (including informal care) that improve the health and functioning of the elderly.
- Assessing the outcomes and effectiveness of clinical, organizational, and social interventions that improve or delay decline of functional status.
- Improving our ability to measure change in functioning across the broad range of functional levels for a diverse aging population and developing strategies to incorporate these functional status measures routinely in clinical practice.
- Understanding how best to integrate preventive, acute, chronic, and long-term (formal and informal) care and coordinate the delivery of care across multiple sites and settings—outpatient, hospital, rehabilitation, subacute care, home care, long-term care (institutional and community care), and community-based social services.
Progress in this area will also require specific attention to the following components of care.
Prevention. Preventive interventions are an integral component of promoting healthy aging, but important gaps remain in our knowledge about the efficacy, appropriateness, and cost-effectiveness of specific preventive strategies in older people. Specific attention needs to be paid to the following issues that affect older people:
- Appropriateness of outcome measures used.
- Effects of comorbidity, competing risk, advanced age, and individual utilities on optimal screening strategies.
- Efficacy of behavioral interventions to reduce risk.
We also need to find ways to improve efficiency and reduce the risks of preventive interventions in older patients.
Chronic care. Eighty-five percent of people age 65 and older report at least one chronic condition; more than half report at least two; and more than a quarter report three or more. Research is needed on the outcomes and effectiveness (including cost-effectiveness) of clinical and organizational interventions that prevent morbidity from these conditions. There is a need to develop working models of collaborative care for chronic illness between doctors and patients, as well as to assess the effectiveness of these models.
Comorbidity. Much research on the elderly has been disease or symptom specific. Research is now needed to understand the impact of comorbidity. While significant progress has been made in the clinical management of common chronic diseases, much less is known about the impact of comorbidity—including both physical and mental health comorbidities—on disease management and clinical outcomes. Competing risks from multiple conditions in an individual will influence patient and physician decisionmaking processes. Comorbidity must also be considered in quality measurement and quality improvement efforts.
Long-term care. Gaps in knowledge for this population include clinical issues and organizational concerns. Information is needed on how to prevent institutionalization, and on cost-effective models of community-based long-term care. Because long-term care creates a large burden on the family, research is needed on improving the effectiveness of informal care, as well as relieving caregiver burden. Improvements are also needed in health status measures in long-term care, especially measures that are adapted for the cognitively impaired, quality measures for long-term care settings, and HRQOL measures.
Best practices across settings of care. We need to learn how to coordinate the delivery of care across multiple sites and settings of care, including outpatient, hospital, rehabilitation, subacute care, home care, long-term care (institutional and community care), and community-based social services. Studies of the cost-effectiveness of rehabilitation, home care, and subacute care can inform the Medicare debate.
Patient decisionmaking. Older people face many complex choices, such as treatment and insurance, about their health care. Studies are needed to determine how to best assure that patients are informed and are active participants in the decisionmaking process. Studies are also needed that focus on improving doctor-patient communication and interpersonal quality of care.
Enhancing patient safety. Unique issues need to be addressed in order to enhance safety for elderly patients. Their unique constellation of comorbidity, use of multiple sites and settings of care, and polypharmacy—within the context of a higher prevalence of functional impairments, including cognitive impairment—places the elderly at increased risk for medical errors. This risk is compounded by the lack of awareness among many providers about general principles of geriatric management.
1 Cohen J, Machlin S, Zuvekas S, et al. Health care expenditures in the United States, 1996. MEPS Research Findings 12, AHRQ Pub. No. 01-0009. Rockville, MD: Agency for Healthcare Research and Quality; 2000
4 Institute of Medicine, Committee on a National Research Agenda on Aging. Extending Life, Enhancing Life: A National Research Agenda on Aging. (Lonergan E, Ed.). Washington, DC: National Academy Press, 1991.
5 Institute of Medicine, Committee to Develop an Agenda for Health Outcomes Research for Elderly People. Health Outcomes for Older People: Questions for the Coming Decade. (Feasley J, Ed.). Washington, DC: National Academy Press, 1996.