Using structured implicit review to assess quality of care in the program of all-inclusive care for the elderly (PAGE)

OBJECTIVE: To develop a quality assessment tool for care rendered to enrollees in the Program for All-inclusive Care of the Elderly (PACE) that can discriminate care quality ratings across PACE sites. DESIGN: Structured implicit review (SIR) of medical records by trained geriatricians and geriatric nurse practitioners. SETTING: Eight PACE sites. PARTICIPANTS: Older adults enrolled in a PACE program for at least 6 months (n = 313). MEASUREMENTS: Process and outcome measures for both overall care and 14 specific conditions (tracers) managed up to 1 year. RESULTS: Overall care quality was judged to be above a community standard in 56% and below standard in 8% of cases. Process of care was rated as very good or good in 70% of the cases. Outcomes depended on how questions were phrased: only 19% of cases improved, whereas 28% were judged to have fared better than expected given their condition at baseline. The SIR method produced ratings demonstrating considerable variability across the sites; three of the sites consistently showed poorer quality ratings than the other five. CONCLUSIONS: PACE care was generally assessed to be of good quality, but with room for improvement. Despite significant limitations of poor interrater reliability for process of care measures, excessive time involved for the reviews, and lack of a control group, the SIR method was able to consistently discriminate quality ratings among PACE sites. A modified version of the assessment instrument could prove useful in a quality improvement program for PACE care.