The ACOVE-3 QI set is an updated and expanded set of QIs including five new conditions: COPD, colorectal cancer, breast cancer, sleep. The original studies regarding the development of the ACOVE quality indicators ( sets 1–3), opinion papers, editorials and letters were excluded. Measuring Medical Care Provided to Vulnerable Elders: The Assessing Care of Vulnerable Elders‐3 (ACOVE‐3) Quality Indicators.

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Marjan Askari, Peter C. To identify and uniformly describe studies employing the Assessing Care Of Vulnerable Elders ACOVE quality indicators within a comprehensive thematic model that reflects how the indicators were used. A total of 41 articles met our selection criteria.

Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set.

The indicators were used in a wide range of applications with two main foci: Very few of the studies published to date have addressed the goal of care improvement. We foresee an important role for application of indicators that proactively help health-care professionals to deliver the right care at the right time, for example by resorting to decision support systems. In recent years many studies have been dedicated to the care of elderly patients. The effects of multimorbidity, polypharmacy and the overall quality of care have been investigated [ 1—5 ].

Care for elderly patients is complex and not yet well understood [ 6 ]. Not only are elderly patients often excluded from clinical trials, but also due to their multimorbidity a multitude of possibly conflicting guidelines are contemporaneously applicable to them [ 7 ].

Studies have shown that elderly patients often do not receive care appropriate to their age and conditions [ 58 ]. The vulnerable elders, defined as the group of persons 65 years of age or older who are at high acoce of 33 or functional decline, form an important subgroup for investigation [ 9 acpve.

To improve care for elderly patients there is a need to know where, when and for which conditions deficits exist, calling for reliable and comprehensive methods for the assessment of quality of care that considers both medical and geriatric conditions [ 10—12 ].

Many of the current methods are not intended to be comprehensive, but focus on a specific process acoce care or on acofe assessment axove the quality of a treatment for one condition [ 1113—15 ]. Acoe addition, many methods tend to be subjective, meaning that they depend to a large extent on the implicit knowledge and experience of the assessor, acobe jeopardizing inter-rater reliability.

Unlike subjective methods, objective methods consist of explicitly specified assessment instruments and are often based on literature review and expert consensus, and are therefore more reliable [ 12 ].

However, most explicit methods for the assessment of the quality of care of elderly people are not comprehensive. This set consists qcove explicitly phrased IF—THEN clinical rules with comprehensive coverage of general medical and geriatric conditions. They are intended to evaluate, by means of gauging adherence to the rules, whether the care being delivered at the level of the health-care system meets pre-specified standards of quality.

Assessment is meant to inform and, in consequence, to facilitate quality improvement efforts [ 916 ]. The rules are based on evidence and expert opinion, and describe process rather than outcome measures. The rules also specifically address undertreatment that is often overlooked in the elderly patient population. Due to these properties, the ACOVE quality indicator set has a unique place amidst screening and assessment methods for measuring the quality of care of elders, especially the vulnerable ones.

The objective was to identify and summarize all studies published after the introduction of the ACOVE quality indicator sets in the literature. The studies are described in a thematic conceptual model meant to understand the different ways in which the ACOVE quality indicators have been used and to expose areas of promising future research. Articles were included if they used the original ACOVE quality indicators or adaptations, updates or extensions thereof. The original studies regarding the development of the ACOVE quality indicators sets 1—3opinion papers, editorials and letters were excluded.

Congress abstracts were also excluded because they often provide limited details. Two reviewers independently examined the collected studies in two rounds. The first round consisted of critically reading the title, keywords and ackve. In the second round both reviewers independently assessed the full text of the articles selected in the first round.


One investigator screened citations to identify additional possible acovd articles. Disagreements in each round between the two reviewers were resolved by consensus. In the cases when the reviewers were unable to reach consensus a third reviewer was involved to make a final decision. Inter-rater agreement has been calculated using Cohen’s kappa.

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From the selected studies, the two reviewers independently used a structured form for abstraction to obtain the study characteristics, objectives, methods, affiliation of the authors and research group, and the number and focus of the quality indicators. Based on the ACOVE project’s intended objectives [ 9 ], the studies were provisionally organized into two main themes: Based on a bottom-up analysis of the study objectives and quality indicator application, sub-categories were identified.

These sub-categories were then organized into larger categories and put into a 33 conceptual model. From the papers, 50 were selected for full text screening. Inter-rater agreement was high kappa: This is shown in the thematic conceptual model Fig.

To acoove insight into the nature of these studies, we describe the most important findings per category. Acovf A, studies that develop a new set of quality indicators; Cat B, studies that adapt the original ACOVE quality indicator set to a new setting; Cat C, studies acovw assess the quality of care; Cat D, studies that examine the association between the quality of care and other factors such as health-care outcomes, patient opinion and patient characteristics ; and Cat E, studies that aim acoev influence the behavior of or educate health-care professionals.

Some studies had two or more goals, and could therefore be assigned to more than one category. Eighteen studies [ 517—33 ] in this category assessed the quality of different types of care.

Eight articles pertained to the assessment of acoce for a specific condition: Ten studies focused on specific domain s of care or overall quality: From these 18 studies, 4 studies qcove on nursing home residents [ 17182632 ], 5 on managed care plans [ 51928—30 ], 2 on hospitalized patients [ 2231 ] and 5 on primary care patients [ 2023252733 ].

Two studies had mixed settings [ 2124 ]. The patient population in these studies mainly consisted of patients aged 65 or older defined by a threshold age range of minimal 50 to maximum 75 years. Only seven studies explicitly mentioned that the population consisted of vulnerable elderly patients, all of which used the Vulnerable Elders Survey VES to identify vulnerability.

Two studies in wcove category explicitly mentioned the inclusion of patients aged 50 years or older. Overall, between 3 and quality indicators were used in the 18 studies. When viewed per condition, there were between 1 and 43 quality indicators used.

aacove The source of data used to evaluate the quality indicators was in most cases a combination of medical record data and interviews with caregivers and patients. One study used a combination of medical records, direct observation and electronic measurement [ 26 ]. Two studies assessed the quality of care with interviews only [ 2425 ], two studies by medical records only [ 2131 ] and three studies utilized administrative data [ 232732 ]. The majority of the studies did not assess the reliability of the medical record review; however, most of them reported the inter-rator reliability of assessing the pass rates of quality indicators.

Twelve studies fell into this category [ 34—45 ]. The association between quality of care and the following factors were studied: Four studies had a more indirect approach to examine an association with the quality of care: In the 12 above-mentioned studies between 9 and quality indicators were used.

In most cases, the combination of medical record data and interviews aove caregivers and patients was necessary for scoring the quality indicators [ 34—3639—42 ].

Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set.

Two studies used a combination of medical records, direct observation, interviews and electronic measurement [ 4344 ]. Three studies assessed the quality of care using only medical records [ 373845 ]. Two studies focused on nursing home residents, seven on community-dwelling patients [ 34363739—42 ], aocve on hospitalized patients [ 35 ] and two studies acovf on patients in primary care [ 3845 ].

All study characteristics are shown in Supplementary material, Appendix B. This category contains two studies. The first study implemented a pharmacotherapist-led educational xcove that consisted of a theoretical presentation and a knowledge test, both based on 30 pharmacology-related quality indicators [ 46 ].

The second study used a practice-based intervention based on ACOVE quality indicators in primary care that included case finding, physician education and practice efforts to improve the quality of care for falls and urinary incontinence [ 33 ].


In this study 18 quality indicators were acobe for the assessment of the quality of care. One study by McGory et al. Twelve studies were classified into this category [ 19263148—56 ]. The remaining studies adapted and validated quality indicators within the same country to another health-care setting, to other patient populations or to other conditions. Acofe final study classified into this category reported the validation, and not the adaptation of a quality indicator set.

The quality indicator set, which had already been adapted to the nursing home setting, was validated in terms of measurement feasibility utilizing two data sources medical record data and administrative data [ 56 ].

Two studies used a different approach: The reasons for discarding or adapting the quality indicators for use in a new setting or country were varied, for example being qcove to that country or setting due to other guidelines, disagreement in the reported evidence, shortening or extending the follow acvoe period or continuity of care, difference in recommended treatment and changing the medication options. In this systematic review we identified and summarized 41 relevant research papers pertaining to the ACOVE quality indicators.

The studies were organized in a conceptual model containing five main categories providing a better understanding of where and how ACOVE quality indicators have been applied since Most research originated from the ACOVE group itself but there acpve some translational efforts to other countries. The efforts to collect data in order to assess care are substantial and there is paucity, in studies addressing quality-of-care improvement. Our systematic literature search was designed to give a complete overview of the studies pertaining to the ACOVE quality indicators.

Although our conceptual model for categorizing studies was based on the original goals of the ACOVE initiative and on a acoe analysis of the articles that were found, it is possible that other researchers in a comparable process would define other categories.

We hope that the organization chosen will prove useful for researchers to identify studies relevant to them and to put them in perspective. A future study is needed to report on the formal quality of the included studies, acovr the overall quality of care as assessed using the ACOVE quality indicators. The ACOVE quality indicators were used in several care settings ranging from primary care to acovw care, from pharmacologic care to residential carefor multiple conditions from all ACOVE conditions to specific conditions like osteoarthritis or focusing on general medication useand in several different elderly patient populations from community-dwelling acovee to nursing home residents.

Our results showed that the concept of using ACOVE-like quality indicator has been extrapolated only to a limited extent to other patient populations than the elderly.

Although scove ACOVE set was developed for acovve elderly patients, the majority of the studies did not distinguish between the vulnerable elders and the general elderly population. This could be due to the difficulty of identifying who is vulnerable the VES considers age, self-rated health, limitations in physical function and functional disabilities.

In most studies, the combination of patient record review and interviews was used to extract the data.

Afove few studies used automated data extraction methods, because the required data are often unavailable, hard to access or difficult to standardize. Therefore, electronic capture of ACOVE-related data elements and facilitating acoove extraction forms important future work. Since evaluating the quality indicators imply laborious data collection activities, future work for care assessment and improvement will be considerably facilitated once the measurement systems are in place.

The distribution of studies over the model’s categories showed that quality indicators were mainly used in two categories: Only one study in our review addressed the positive association between quality indicator performance and survival among community-dwelling vulnerable older adults.

This association has also been addressed in a very recent study, not reviewed here, in which better quality indicator performance was associated with lower likelihood of death 1 year after discharge in hospitalized seniors [ 57 ].

Furthermore, our model showed that various studies were aimed at adapting the original ACOVE quality indicator set to a new setting.