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- Report of a Forum of the
Council on Heady Care Technology
Care of the Elderly Patient:
Policy Issues and
Research
Opportunities
Jeremiah A. Barondess,
David E. Rogers, and
Kathleen N. Lohr, editors
l
Institute of Medicine
NATIONAL ACADEMY PRESS · WASHINGTON, D.C. · 1989
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TO INSllTlTrE OF MEDICINE was chartered in 1970 by the National
Academy of Sciences to enlist distinguished members of appropriate professions
in the examination of policy matters pertaining to the health of the public. In this,
the Institute acts under both the Academy's 1863 congressional charter responsi-
bility to be an adviser to the federal government, and its own initiative in
identifying issues of medical care, research, and education.
THE COUNCIL ON HEALTH CARE TECHNOLOGY was established
in 1986 by the Institute of Medicine of the National Academy of Sciences as a
public-private entity to address issues of health care technology and technology
assessment. The council is committed to the well-being of patients as the
fundamental purpose of technology assessment. In pursuing that goal, the council
draws on the services of the nation's experts in medicine, health policy, science,
engineering, and industry.
The Forum and this monograph were supported in part by a grant to the
Council on Health Care Technology of the Institute of Medicine from the Na-
tional Center for Health Services Research of the U.S. Department of Health and
Human Services (grant 5 R09 HS055 26 02~. The opinions and conclusions
expressed here are those of the authors and do not necessarily represent the views
of the Department of Health and Human Senices, the National Academy of
Sciences, or any of their constituent parts.
Library of Congress Catalog Card Number 89~2106
International Standard Book Number ~309-04097-3
Additional copies of this report are available from:
National Academy Press
2101 Constitution Avenue, NW
Washington, DC 20418
Printed in the United States of America
S031
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ACKNOWLEDGMENTS
.
- The Forum on Care of the Elderly Patient: Policy Issues and
Research Opportunities would not have been possible without the dedi-
cated efforts of Leslie Hardy, who, as a staff officer of the Council on
Health Care Technology at the time, devoted long hours to the logistics of
the meeting. Sunilarly, the publication of this monograph would not have
been possible without the many hours of skinny and cheerful preparation
of several drafts~of this manuscript by Brenda Patterson of the council
staff. The original version of these papers was most competently edited
by Heather Wiley. On behalf of He members of the~council and the
authors in this volume, the editors thank them aD for their contributions.
The editors wish to thank Enriqueta Bond, former Director of the
Division of Heals Promotion and Disease Prevention, for her substantial
contributions to the council~and-its activities. They are grateful as wed to
Samuel O. Thier, President of He Institute of Medicine, for inspired
leadership and support of the council initiatives. Finally, they acknowI-
edge a considerable debt to William N. Hubbard, Ir., chairman of the
council, and to Jeremiah A. Barondess, co-chairman; their blend of guid-
ance and support through the past year has made this form and the entire
forum series possible.
.
· · ~
111
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Council on
Health Care Technology
Chairman
WILLIAM N. HUBBARD, JR., M.D.
Former President, The Upjohn
Company
Co-Chairman
JEREMIAH A. BARONDESS, M.D.
Irene F. and I. Roy Psaty
Distinguished Professor of Clinical
Medicine, Cornell University
Medical College
Members
HERBERT E. ABRAMS, M.D.
Professor of Radiology, Stanford
University School of Medicine ~
RICHARD E. BEHRMAN, M.D.
Dean, School of Medicine, Case
Western Reserve University
PAUL A. EBERT, M.D.
Director, American College of
Surgeons
PAUL S. ENTMACBR, M.D.
Senior Vice President and Chief
Medical Director, Metropolitan
Life Insurance Company
MELVIN A. GLASSER
Director, Health Security
Action Council
BENJAMIN L. HOLMES
Vice President and General Manager,
Medical Products Group,
Hewlett-Packard Company
1V
GERALD D. LAUBACH, Ph.D.
President, Pfizer Inc.
. .
WALTER B. MAZIER
Director, Employee Benefits,
Chrysler Motors Corporation
WAYNE R. MOON
Executive Vice President and
Operations Manager, Kaiser
Foundation Health Plan, Inc.
LAWRENCE C. MORRIS, JR.
Senior Vice President, Health
BeneSts Management, Blue
Cross and Blue Shield Association
C. FREDERICK MOSTELLER, Ph.D.
Roger I. Lee Professor (Ementus),
Director, Technology Assessment
Program, Harvard School of
Public Health
MARY O. MUNDINGER, Dr.P.H.
Dean, School of Nursing,
Columbia University
ANNE A. SCITOVSKY
Chief, Health Economics
Department, Palo Alto
Medical Foundation
GAIL L. WARDEN
President, Henry Ford Health
Care Corporation
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PREFACE
In the recent past, the interests of different groups concerned with
health care have focused on the use of medical technologies~heir safety,
efficacy, and effectiveness; their cost-effectiveness and cost-benefit; their
impacts on quality of care; and their social, legal, and ethical implications.
The sum of these varied interests is the field of health care technology
assessment.
The Council on Health Care Technology was created to promote
He development and application of technology assessment in health care
and the review of health care technologies for their appropriate use. The
council was established as a public-private enterprise at the Institute of
Medicine, a component of the National Academy of Sciences, Hugh the
Health Promotion and Disease Prevention Amendments of 1984 (P.L.
9~55l, later amended by P.L. 9~171. In 1987 the U.S. Congress
extended support for the council as a public-private venture for an addi-
tional three years (by P.L. 10~1771.
The goals and objectives of the council, as stated in the report of its
first two years of operations, are "to promote the development and appli-
cation of technology assessment in medicine and to review medical tech-
nologies for their appropriate use. The council is guided in its efforts by
the belief that the fundamental purpose of technology assessment is to
improve patient wet/-being and the quality of care." In pursuing these
goals, the council seeks to improve the use of medical technology by
developing and evaluating the measurement criteria and the methods used
for assessment; to promote education and training in assessment methods;
and to provide technical assistance in the use of data from published
assessments.
The council conducts its activities through several working and
liaison panels. Members of these panels reflect a broad set of interested
constituencies physicians and other health professionals, patients and
their families, payers for care, biomedical and health services researchers,
manufacturers of health-related products, managers and administrators
throughout the health care system, and public policymakers. In addition,
the council carries out activities of interest to more than one panel.
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V1
PREFACE
The Forum Series is one of the councilwide activities. The Forum
Series seeks to facilitate an exchange of views among the many and
diverse groups concemed with health care technology. Themes addressed
by these symposia include He interdependence among medical technol-
ogy assessment, quality assessment, and assurance of the quality of pa-
tient care; the performance of existing technology assessment activities;
the appropriate use of technology to minimize risks posed to special or
vulnerable patient populations; and He development, application, and
appropriate use of technology.
A guiding principle of the council is a special focus on outcome
measures that coincide with patient wet/-being, quality of health care, and
quality of life. In keeping with this pnnciple, a forum conducted in
October 1987 dealt win care of the elderly patient. This report is the
record of that symposium.
William N. Hubbard, Ir., Chairman
Jeremiah A. Barondess, Co-Chairman
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CONTENTS
Introduction to He Council on Health Care Technology
William N. Hubbard, Jr.
Quality of Care and He Health Needs of the Elderly Patient 3
Avedis Don~bedian
Home and Community Care of the Elderly: Introduction
Mary 0. Mundinger
....... ~4
Home and Community Care of the Elderly: Framing the Issues 16
Robert L. Kane
Framing the Issues of Home and Community Care: Response 28
Earl M. Collier, Jr.
Special Perspectives on Home land Community Care 32
Patricia P. Barry
Special Perspectives on Home and Community Care 36
Eileen M. Quinlan
Special Perspectives on Home and Community Care
Susan A. Walker
Special Perspectives on Home and Community Care
Charlotte K. Flynn
44
.48
Special Perspectives on Home and Community Care 52
Lynn M. Etheredge
Home and Community Care of the Elderly: System Resources and
Constraints ~ a~ en e
Susan L. Hughes
Home and Community Care of the Elderly: System Resources and
Constraints
John H. Mather
Home and Community Care of the Elderly: Research and
Policy Issues ...................................................................................
Bruce C. Viadeck
· —
V11
........ 65
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~ · ~
V111
CONTENTS
Home and Community Care of the Elderly: Research and
Policy Issues e~ e-~-e~ e~eeeeeeeeee~eeeeaeeeee-eeeeeeee~eieeae~-eee~
Lisa V. Rubenstein
71
The Acute Care Hospital and the Elderly: Introduction .~ eee.~ 77
Jeremiah A. Barondess
The Acute Care Hospital and the Elderly: Framing the Issues
Mitchell T. Rakkin
80
Special Perspectives on Acute Hospital Care 87
William R. Hazzard
Special Perspectives on Acute Hospital Care
Carol ]. Gray
............
...94
Special Perspectives on Acute Hospital Care 103
lack E. Christy
Special Perspectives on Acute Hospital Care 109
Joseph W. Westbrook
Acute Hospital Care of the Elderly: System Resources and
Constraints 1
]. Alexander McMahon
Acute Hospital Care of the Elderly: System Resources and
Constraints
L. Gregory Pawlson
Acute Hospital Care of the Elderly: Research and Policy Issues
Jerome Kowal
Acute Hospital Care of the Elderly: Research and Policy Issues .
Stephen R. McConnell
,14
124
....... 132
Care of the Elderly Patient: Summation of He Forum 136
David E. Rogers
List of Authors
