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Editorial

Towards elder-friendly outpatient services

Chen, Liang-Kung*

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Journal of the Chinese Medical Association: December 2012 - Volume 75 - Issue 12 - p 617-618
doi: 10.1016/j.jcma.2012.08.017

    Aging populations are a global phenomenon that affect both developing and developed countries, and Taiwan is no exception. Taiwan became an “aging” country in 1993 (the point at which the percentage of people aged over 65 years reaches 7% of the total population), and estimates suggest that it may become an “aged” country in 2017 (the point when the elderly population becomes 14% of the total population). These figures indicate a Taiwanese rate of population aging that is accelerating even more quickly than that of Japan, which is recognized to be one of the fastest aging countries in the world.1

    An escalating elderly population poses various challenges for healthcare systems because the health characteristics and complexity of care necessary for older people differ extensively from those needed for the younger population, and this population merits a specific healthcare service system.2 It has been shown that outpatient service utilization is very high in Taiwan, in that 96.6% of elderly people have used outpatient services at least once a year; on average, older Taiwanese individuals make nearly 27 outpatient visits annually.3 Moreover, approximately 65% of those people who utilize outpatient services in Taiwan may have been prescribed at least one potentially inappropriate medication in a year, which may be the highest proportion in the world.4 These findings clearly indicate that, although older Taiwanese visit outpatient services facilities frequently, they do not obtain optimal quality of care, which is shown in part by the high prevalence rate of inappropriately prescribed medications.

    In the previous issue of the Journal of the Chinese Medical Association, Kuo et al report on a qualitative study to identify strategies to improve outpatient services for elderly patients in Taiwan. The results of this study show that older people expect longer consultations, a clear explanation of the possible complications of check-ups or treatment, and the feeling that their opinions are being respected.5 Although these factors seem to be a common phenomenon in Taiwan, Kuo et al's results clearly demonstrate the need for elder-friendly healthcare services. Unlike previous studies examining the quality of outpatient services in Taiwan by using the claims data from the National Health Insurance scheme that evaluated physicians' prescribing behavior and patients' patterns of healthcare utilization, this study explored the need for different outpatient services from the perspective of older patients themselves. The above-mentioned conditions also implied that greater improvement has to be made in the process of providing outpatient care. Furthermore, the quality of health system practices as they affect older patients also deserves further attention, in part to reduce the inappropriate prescribing of medication.

    Proving healthcare services for the elderly population is a huge challenge, which should be addressed using a brand new approach. Asch et al reported that the elderly population in the United States receives less-than-average medical care, which suggests a substandard utilization of both inpatient and outpatient services.6 However, another report indicated that adherence to current clinical practice guidelines in caring for an older patient with multiple co-morbidities may lead to inappropriate medical judgment and unwanted clinical outcomes.7 Since most clinical practice guidelines have been developed to treat a single condition, with little or no specific consideration given to older patients, those older patients with multiple co-morbid chronic conditions and complex care needs cannot be properly managed in such circumstances. In particular, in Taiwan, patients have the freedom to consult any specialist of their own choosing, which aggravates these problems.

    Recommended solutions to these difficulties include addressing additional geriatric considerations in current medical practice. It has been shown that the quality of care for older people can be significantly improved by geriatric evaluation and management (GEM), an integrated geriatric service model that significantly prevents the functional decline of older patients, but does not impact on mortality rates.8 Although the mortality of older patients cannot be reduced by GEM services, pursuing an improved, active quality of life rather than merely prolongation of life is the key concept of geriatric services, and this is compatible with the current theory of the rectangularization of mortality.

    The benefits of improved outpatient geriatric services have been manifest in that outpatient geriatric services have significantly reduced overall medical utilization and the burden of morbidity in elderly people, which has substantial implications for primary healthcare settings.9 Although integrated outpatient geriatric services may not be provided universally, implementation of comprehensive geriatric assessment in outpatient settings is considered an explicit goal, in part to relieve the burden of multimorbidities and treatment in caring for older people.10

    Due to the escalation in size of the elderly population in Taiwan, and the coinciding constraints on healthcare expenditures, maintaining the current outpatient practice model in Taiwan may not be sustainable in the future. Establishing an elder-friendly healthcare service system is of critical importance, and a system capable of treating older patients with multimorbidities and complex care needs is essential to meet the challenges related to population aging. Integrated outpatient geriatric services, or services including the implementation of comprehensive geriatric assessment, significantly improve the quality of care and may echo the results of Kuo et al's report in the previous issue of the Journal of the Chinese Medical Association.

    Liang-Kung Chen

    Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan, ROC

    Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC

    References

    1. Lin MH, Chou MY, Liang CK, Peng LN, Chen LK. Population aging and its impacts: strategies of the health-care system in Taipei. Ageing Res Rev. 2010;9(Suppl 1):S23-S27.
    2. Chen CY. Meeting the challenges of eldercare in Taiwan's aging society. J Clin Gerontol Geriatr. 2010;1:2-4.
    3. Lin YT, Hwang SJ, Chen LK, Chen TJ, Hwang IH. Ambulatory health care utilization of the older people under the National Health Insurance in Taiwan. J Clin Gerontol Geriatr. 2011;2:53-57.
    4. Lai HY, Hwang SJ, Chen YC, Chen TJ, Lin MH, Chen LK. Prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients covered by the Taiwanese National Insurance program. Clin Ther. 2009;31:1859-1870.
    5. Kuo RJ, Wu YH, Hsu TS. Integrating of fuzzy theory and TOPSIS into HFMEA to improve outpatient service for elderly patients in Taiwan. J Chin Med Assoc. 2012;75:341-348.
    6. Asch SM, Sloss EM, Hogan C, Brook RH, Kravitz RL. Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA. 2000;284:2325-2333.
    7. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716-724.
    8. Cohen HJ, Feussner JR, Weinberger M, Carnes M, Hamdy RC, Hsieh F, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002;346:905-912.
    9. Tao P, Lin MH, Peng LN, Lee WC, Lin FY, Lee CH, et al. Reducing the burden of morbidity and medical utilization of older patients by outpatient geriatric services: implications to primary health-care settings. Geriatr Gerontol Int. 2012;12:612-621.
    10. Hsiao FYS. Improving care for older people: where can we start? J Clin Gerontol Geriatr. 2011;2:33-34.
    © 2012 by Lippincott Williams & Wilkins, Inc.