Appendix A.2.
A Case Series of Comorbidity and Complexity in Assessing Care of Vulnerable Elders 2 The following comorbid condition combinations were used to identify subsamples of individuals with increasing complexity.
| R o w |
Hypertension | CAD | DM | AF | Dementia | N | Mean Simple Count |
Mean GXI Score |
Number of QIs Eligible, Mean±SD |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Absent | Absent | Absent | Absent | Absent | 88 | 1.6 | 24 | 9.4±3.2 |
| 2 | Present | Absent | Absent | Absent | Absent | 182 | 2.8 | 25 | 10.6±3.5 |
| 3 | Present | Present | Absent | Absent | Absent | 86 | 4.3 | 35 | 12.5±3.7 |
| 4 | Present | Present | Present | Absent | Absent | 38 | 5.2 | 41 | 16.0±4.0 |
| 5 | Present | Present | Present | Present | Absent | 8 | 6.3 | 48 | 17.8±4.8 |
| 6 | Present | Present | Present | Present | Present | 3 | 7.7 | 51 | 22.0±4.6 |
One to two individuals were selected from each row for qualitative review based on having a low (where possible) versus high complexity score.
Row 1 Individual without complex care needs (Screened by ACOVE for urinary incontinence (UI) and falls): A 78-year-old man without a diagnosis of hypertension, coronary artery disease (CAD), diabetes mellitus (DM), atrial fibrillation (AF), or dementia. The patient had history of prehypertension (2), mild chronic kidney disease (CKD) (2), fall with fracture (5), mild stable anemia (2), obesity (3).
Complexity score: 14 (~15th percentile)
Simple comorbidity count = 1
No polypharmacy (≤6 medications)
Primary care provider visits = 5
No specialty care
NQI (5 QIs to be documented in the medical record, and an additional 11 to be collected by interview):
Gait and balance evaluation
Weighed at each visit
Education for new medication (I)
Drug regimen review annually (I)
Counsel calcium and vitamin D intake (I)
Counsel weight bearing exercise (I)
Discuss risk for OP risks and prevention (I)
Recommend calcium and vitamin D for OP (I)
Screen pain every 2 years (I)
Advance directive or surrogate in OP charts
Pneumococcal vaccine
Annual influenza vaccine
Screen and take history alcohol use (I)
Assessment or counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
Row 1 Individual with Complex Care Needs (Screened by ACOVE for falls): A 77-year-old man also without hypertension, CAD, DM, AF, or dementia.
The individual had prehypertension (2), anemia with mild decline (4), chronic nonsevere pain (5), old hypothyroidism (2), history of fall with fracture (5), history of osteoporosis (OP) with fracture (4), comorbid insomnia and anxiety with new depression (8), smoked in the past but not presently (1), stable CKD (Stage 4 or 5) (5), tobacco history (1), fatigue (5), problematic alcohol use (6), new bothersome UI symptoms (4).
Complexity score: 51 (~95% percentile)
Simple comorbidity count = 3
Moderate polypharmacy (7–9 medications)
Primary care provider visits = 13
Specialty care: 6 specialist visits (neurology, other medical specialty, psychiatry)
NQI (21 QIs to be documented in the medical record, and an 17 additional QIs to be collected by interview:
Depression symptoms, screen within 2 weeks
Document 3 of 9 DSM-IV symptoms
Document suicidality and psychosis
Treat depression within 2 weeks
If depressed, do not prescribe tricyclics, monoamine oxidase inhibitors, benzodiazepines, or stimulants (except methylphenidate) as first- or second-line therapy
Take a falls history for fall
Perform a fall examination
Perform a gait and balance examination for balance problem (I)
Audiologist teach how to use hearing aid (I)
Weigh at each visit
Follow-up response to new medications
Drug regimen review annually (I)
Check electrolytes within 1 month of starting diuretics
Assess function and pain annually (I)
Recommend physical therapy for OA pain within 3 months (I)
Education for self-management of OA > symptomatic 6 months (I)
Acetaminophen 1st line med for OA (I)
Counsel calcium and vitamin D intake (I)
Counsel weight-bearing exercise (I)
Discuss risk for OP risks and prevention (I)
Recommend calcium and vitamin D for OP (I)
Screen pain every 2 years (I)
History for pain within 1 month
Examination for pain within 1 month
Offer bowel regimen for chronic opioids
Offer treatment for new pain (I)
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Screen and take history alcohol use (I)
Assessment or counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
New UI: take history within 3 months
New UI: perform examination within 3 months
New or persist UI: test urinalysis
New UI: perform post void residual before pharmacological therapy
New UI: discuss treatment options within 3 months
Row 2 individual without complex care needs (Screened by ACOVE for falls): An 85-year-old woman with hypertension only and none of the other conditions.
The individual had well-controlled hypertension (2), normal weight without recent changes (0), new fear of falling or fall (5), OP without fracture (2), stable history of hearing impairment (2).
Complexity score: 11 (~2nd percentile)
Simple comorbidity count = 3
No polypharmacy
Primary care provider visits = 5
Specialty care: 1 visit
NQI (6 QIs to be documented in the medical record, and an additional 12 to be collected by interview):
Perform falls history (I)
Perform a falls examination
Gait and balance evaluation (I)
Weigh at each visit
Drug regimen review annually (I)
Annual electrolytes for diuretic use
Counsel calcium and vitamin D intake (I)
Counsel weight-bearing exercise (I)
Discuss risk for OP risks and prevention (I)
Recommend calcium and vitamin D for OP (I)
Screen pain every 2 years (I)
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Screen and take history alcohol use (I)
Assessment and counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
Row 2 Individual with Complex Care Needs (Screened by ACOVE for worsening UI): An 80-year-old woman with hypertension and none of the other conditions.
The individual had hypertension with high blood pressure (BP) (≥2 high BP readings (140–160 mmHg)) (3). She also had normal hemoglobin at the beginning of the study but with a 0- to 2-mg/dL change during the study period (2), chronic nonsevere pain (5), old hypothyroidism (2), normal weight but with >10% weight loss during the study (4), stable, mild CKD (Stage 2) (2), old hearing problem (2), old vision problem (3), new osteoporotic fracture (6), fatigue (5), insomnia (2), new or bothersome urinary symptoms (4).
Complexity score: 40 (~80th percentile)
Simple comorbidity count = 3
Moderate polypharmacy (7–9 medications)
Primary care provider visits = 12 (saw another provider during time frame, died before assigned primary care provider visit).
Specialty care: 9 visits to a medical specialty
NQI (17 QIs to be documented in the medical record, and an additional 16 to be collected by interview):
Gait and balance evaluation (I)
New depression symptoms, screen within 2 weeks
Counsel nonpharmacological treatment of hypertension (I)
Perform an intervention (any including diet, exercise, counseling) for high BP
Education for new medication (I)
Drug regimen review annually (I)
Weigh at each visit
Document weight loss
Evaluate reversible causes of malnutrition
Evaluate for comorbidities and medications that can cause loss of appetite
Calcium and vitamin D if on steroids for >1 month
Assess function and pain annually (I)
Recommend physical therapy for OA pain within 3 months (I)
Refer to surgery for severe hip and knee OA (I)
Counsel weight-bearing exercise (I)
Discuss risk for OP risks and prevention (I)
Recommend calcium and vitamin D for OP (I)
Screen pain every 2 years (I)
History for pain within 1 month
Examination for pain within 1 month
Offer treatment for new pain
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Screen and take history alcohol use (I)
Assessment and counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
New UI: take history within 3 months
New UI: examine within 3 months
New or persistent UI: order urinalysis
New UI: perform postvoid residual before pharmacological intervention (I)
New UI: Discuss treatment options within 3 months
Row 3 Individual with Moderately Complex Care Needs (Screened by ACOVE for falls): A 79-year-old woman with hypertension and CAD.
The patient had well-controlled hypertension (2), the CAD was old or asymptomatic (2), and there was no history of MI. She had history of fall or fear of falling (5), new OP (3), chronic pain (5), mild but stable anemia (2), normal stable weight (0), history of depression (3), mild stable CKD (estimated glomerular filtration rate 60–90 mL/min per 1.73 m2) (2).
Complexity score: 24 (~23th percentile)
Simple comorbidity count = 4
Severe polypharmacy (10–13 medications)
Primary care provider visits = 6
Specialty care: 2 visits (medical subspecialist)
NQI (12 QIs to document in the medical record and an additional 13 to be collected in interviews):
Take fall history
Perform fall examination
Gait and balance evaluation (I)
Aspirin for patient with CAD
Weigh at each visit
Annual medication review (I)
Advise risk for NSAIDs (I)
If started on chronic NSAID offer gastric protection
Treatment for new OP
Counsel calcium and vitamin D intake (I)
Counsel weight bearing exercise (I)
Discuss risk for OP and prevention (I)
Recommend calcium and vitamin D for OP (I)
Screen pain every 2 years (I)
History for pain with 1 month
Examination for pain with 1 month
Offer treatment for new pain
Assess response to pain treatment (I)
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Screen and take history alcohol use (I)
Assessment and counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
Row 3 Individual with Complex Care Needs (Screened by ACOVE for falls): A 77-year-old woman with hypertension and CAD.
She had well-controlled hypertension (2). Her diagnosis of CAD was old. and she is currently asymptomatic, but she had a new MI within past 2 years (5) and a history of nonsevere congestive heart failure (3). She also had chronic nonsevere pain (5), mild but stable anemia (2), stable CKD Stage 3 (3), breast cancer that was old or not active (3), old hypothyroidism (2), weight was stable and normal (0), new falls problem with new fracture (6), old OP diagnosis (2), comorbid insomnia and anxiety and old depression (7), known hearing problem (2), chronic pain (5) old bothersome UI (3), medical nonadherence (7).
Complexity score: 57 (~97th percentile)
Simple comorbidity count = 5
Very severe polypharmacy (≥14 medications)
Primary care visits = 4
Specialty care: 3 visits total (neurology and psychiatry)
NQI (10 QIs to be documented and another 10 to be collected by interview):
Take fall history
Perform fall examination
Aspirin for patient with CAD
Weigh at each visit
Document weight loss
Evaluate reversible causes of malnutrition
Evaluate for comorbidities and medications that can cause loss of appetite
Assess function and pain annually (I)
Education for self-management of OA symptomatic for >6 months (I)
Offer acetaminophen as first-line therapy for OA (I)
Refer to surgery for severe hip and knee OA (I)
Recommend calcium and vitamin D for OP (I)
History for pain within 1 month (I)
Examination for pain within 1 month (I)
Screen pain every 2 years (I)
Offer treatment for new pain (I)
Assess response to new pain treatment (I)
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Row 4 Moderately Complex Patient (Screened by ACOVE for falls): A 82 year-old man with hypertension and CAD and DM.
The patient had hypertension with mildly high BP (3), the CAD was old/asymptomatic and without history of MI (2), diabetes was well controlled (hgbA1c all ≤8, without significant CKD) (4). He also had mild but stable anemia (hgb 12–14) (2), history of prostate cancer (2), overweight but with weight loss (2), new fall/fear of falling (5), and past smoking (1).
Complexity score: 21 (~20th percentile)
Simple comorbidity count = 4
Moderate polypharmacy (7–9 medications)
Primary care provider visits = 6
Specialty care: 5 total visits (urology and other surgical specialty)
NQI (12 QIs to document and another 11 to collect in interviews):
Annual HbA1c
Check BP at each visit if diabetic
Annual proteinuria test if diabetic
Offer intervention for hypercholesterolemia and DM (I)
Daily aspirin therapy for diabetes
ACE-I or ARB for cardiac risk and DM
Annual foot examination (I)
Gait and balance examination
Aspirin for individual with CAD
Offer nonpharmacological intervention for hypertension (I)
Once or twice daily dosing for hypertension treatment (I)
Weigh at each visit
Annual medication regimen review (I)
Annual electrolytes for diuretic
Recommend calcium and vitamin D for OP (I)
Screen for pain every 2 years (I)
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Screen and take history alcohol use (I)
Assessment and counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
Row 4 Individual with Complex Care Needs (Screened by ACOVE for falls): An 87-year-old woman with hypertension and CAD and DM.
The individual had hypertension (moderately well controlled, with mildly high BP (3), CAD that was old and asymptomatic but with new recent MI (5), controlled DM without CKD (4). She also had history of well-controlled hypercholesterolemia (2), history of nonsevere cerebrovascular disease (CVD) (3.5), morbidly obese (6), history of falls with old fracture (5), anxiety (6), smoked in the past (1), old hearing (2) and vision problem (3).
Complexity score: 40.5 (~80th percentile)
Simple comorbidity count = 4
Moderate polypharmacy (7–9 medications)
Primary care provider visits = 4
Specialty care: none
NQI (10 QIs to document in the medical record, and another 19 to be collected by interview):
Offer intervention for hypercholesterolemia and DM (I)
Annual HbA1c
Annual proteinuria test
Check BP at each visit if diabetic
Daily aspirin therapy for DM
Annual foot examination (I)
Aspirin for CAD
Stroke prophylaxis for CVA
Take fall history
Perform fall examination
Gait and balance examination for balance problem (I)
Audiologist counseling if qualifies for hearing aids (I)
Offer nonpharmacological intervention for hypertension (I)
Once or twice daily dosing for hypertension treatment (I)
Annual medication review (I)
Recommend calcium and vitamin D for OP (I)
Assess pain and function annually in OA (I)
Education for self-management of OA symptomatic for >6 months (I)
Screen for pain every 2 years (I)
Counseling weight-bearing exercise (I)
Weighed at each visit
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Discuss risk for OP and prevention (I)
Screen and take history alcohol use (I)
Assessment and counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
Row 5 Individual with Moderately Complex Care Needs (Screened by ACOVE for falls): A 79-year-old man with hypertension, CAD, DM, and AF.
The individual had controlled hypertension, the CAD was old or asymptomatic and without history of MI, well-controlled DM, AF that was old and stable (without embolic history). He also had Stage 3 CKD, a new diagnosis of CVD with severe stenosis, history of well-controlled hypercholesterolemia, past history of smoking, old hypothyroidism, normal stable weight, old hearing problem, new falls problem but without fracture.
Complexity score: 30 (~50th percentile)
Simple comorbidity count = 6
Severe polypharmacy (10–13 medications)
Primary care provider visits = 8
Specialty care: 14 visits (neurology, urology, other medical subspecialty, other surgical specialty)
NQI (15 QIs to document in the medical record, and another 23 to collect by interview) :
Annual HbA1c
Annual proteinuria test (I)
Check BP at each visit if diabetic
Daily aspirin therapy for DM
Offer intervention for hypercholesterolemia and DM (I)
Annual foot examination (I)
ACE-I or ARB for cardiac risk and DM
Take fall history
Perform fall examination
Gait and balance examination for balance problem (I)
Offer nonpharmacological treatment for hypertension (I)
Once or twice daily dosing for hypertension treatment (I)
Aspirin for patient with CAD
Anticoagulant for high-risk AF
CVA stroke prophylaxis for recurrent stroke
Weigh at each visit
Education for new medication (I)
Annual medication review (I)
Warfarin monitoring every 6 weeks
Check electrolytes within 1 month of starting diuretics
Assess function and pain annually (I)
Recommend physical therapy for OA pain within 3 months (I)
Education for self-management of OA symptomatic for >6 months (I)
Acetaminophen first-line medication for OA (I)
Counsel calcium and vitamin D intake (I)
Counsel weight-bearing exercise (I)
Discuss risk for OP risks and prevention (I)
Recommend calcium and vitamin D for OP (I)
Screen pain every 2 years (I)
History for pain within 1 month
Examination for pain within 1 month
Pneumococcal vaccine
Annual influenza vaccine
Discuss risk for OP and prevention (I)
Screen and take history alcohol use (I)
Assessment and counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
Row 5 Individual with Complex Care Needs (Screened by ACOVE due falls): A 75-year-old man with hypertension, CAD, DM, and AF.
The individual had well-controlled hypertension (2), CAD that was old and asymptomatic and an MI within 2 years (5), well-controlled DM (4) but with stable severe CKD (5 points for CKD plus additional 2 points for CKD+DM combination), and the AF was old and stable without embolic history (4). In addition, he had CHF that was well controlled and nonsevere with preserved ejection fraction (3), new hypercholesterolemia (2), severe peripheral artery disease (6) , stable anemia (2), new falls problem without fracture (5), smoking history not current (1), new-onset or worsening memory but without diagnosis of dementia (5), problematic alcohol use (6), vision impairment (3), benign prostatic hyperplasia (3), newly diagnosed depression (7), chronic pain (5).
Complexity score: 70 (~99th percentile)
Simple comorbidity count = 6
Moderate polypharmacy (7–9 medications)
Primary care provider visits = 7
Specialty care: none
NQI (21 QIs to be documented in the medical record and an additional 11 to be collected in interviews):
Failed memory screen, assess memory
New depression symptoms, screen within 2 weeks
New depression: document 3 of 9 DSM-IV symptoms
New depression: document suicidality and psychosis
Treat depression within 2 weeks
Annual HbA1c
Annual proteinuria test
Check BP at each visit if diabetic
Daily aspirin therapy for DM
Offer intervention for hypercholesterolemia and DM (I)
Take fall history
Perform fall examination
Offer nonpharmacological treatment for hypertension (I)
Once or twice daily dosing for hypertension treatment (I)
ACE-I if HTN and renal insufficiency
ASA for CAD
Anticoagulant for high-risk AF
Stroke prophylaxis for CVA (I)
Weighed at each visit
Follow-up response to new med
Warfarin monitoring 6 weeks
Annual electrolytes for diuretic
Annual medication review (I)
Screen for pain every 2 years (I)
Endocarditis prophylaxis for risk procedures (I)
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Screen and take history alcohol use (I)
Assessment and counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
Row 6 Individual with Very Complex Care Needs (Screened by ACOVE for all three conditions: falls, dementia and UI): A 76-year-old woman with hypertension, CAD, DM, AF, and dementia.
The individual had ≥2 moderately high SBP readings (3), CAD that was old but with ongoing symptoms and history of MI (5), controlled DM (4) with stable Stage 3 CKD (3, with no additional points for the combination of DM and CKD at these levels of severity), AF that was old and without embolism (4), and her dementia was an existing diagnosis without psychiatric symptoms (4). She also had severe chronic obstructive pulmonary disease (COPD) (6), history of well-controlled hypercholesterolemia (2), history of nonsevere CVD (4.5), nonsevere chronic congestive heart failure (6.5), chronic severe pain (7), severe anemia with decrease in Hgb >2 mg/dL (5), old hypothyroidism (2), new falls problem without fracture (5), anxiety with comorbid depression (7), normal weight without weight loss (0), new or bothersome UI (4).
Complexity score: 72 (the most complex person in the sample)
Simple comorbidity count = 9
Very severe polypharmacy (≥14 medications)
Primary care provider visits = 14
Specialty care (2 total visits): psychiatry
NQI (26 QIs to be documented in the medical record and an additional 15 to be collected in interviews):
Counseling about cholinesterase inhibitors in dementia (I)
Dementia: provide caregiver education about safety, conflicts and resources
Annual HbA1c
Annual proteinuria test
Check BP at each visit if diabetic
Daily aspirin therapy for DM
Cholesterol intervention for DM
Annual foot examination (I)
ACE-I or ARB for cardiac risk factors and DM
Offer non-pharmacologic therapy for hypertension (I)
Fall history (I)
Fall examination (I)
Gait and balance examination
ACE-I or ARB for heart failure and low ejection fraction
Intervene to decrease low-density lipoprotein cholesterol if >130 mg/dL and CHD
Aspirin for CAD
Beta-blocker after MI in the past 2 years (I)
Anticoagulant for high risk AF
CVA stroke prophylaxis against recurrent stroke
Weigh at each visit
Warfarin monitoring 6 weeks
Electrolytes within 1 month for diuretic
Annual medication review (I)
History for pain within 1 month
Examination for pain within 1 month
Offer treatment for new pain
Counsel weight-bearing exercise (I)
Discuss risk for OP risks and prevention (I)
Screen pain every 2 years (I)
Advanced directives or surrogate in outpatient charts
Pneumococcal vaccine
Annual influenza vaccine
Screen and take history alcohol use (I)
Assessment and counseling to increase physical activity (I)
Colon cancer screening (I)
Eye examination every 2 years (I)
New UI: take history within 3 months
New UI: examine within 3 months
New or persistent UI: order urinalysis
New UI prescription medication: postvoid residual before pharmacological therapy (I)
New UI: Discuss treatment options within 3 months
I = QI strictly collected in interviews (cannot be collected from the medical record). All other QIs are obtained strictly from medical record or can be collected from the medical record or interview.
NQI= number of quality indicators (QIs); HbA1c= glycosylated hemoglobin; ACE-I= angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; DSM-IV= Diagnostic and Statistical Manual of Mental Diseases, Fourth Edition.