Clinical Burden, Quality of Care, Organizational Context: Different Lenses to Optimize Care for Older People

Abstract

For many practitioners in geriatrics, the primary mission in caring for frail older people (especially those with dementia) is to optimize their quality of life. This is often achieved, at least in part, by reducing their clinical symptom burden, which is particularly relevant in endof-life care. Although recent advances have focused on improving the pharmacologic and nonpharmacologic modalities of symptom reduction at the level of an individual patient, we must remember that a system-based approach to improve the quality-of-care provision can have a larger impact on groups of patients,1,2 and when such quality improvement results in an organizational or contextual change, the impact can become more sustainable over time.3 In other words, clinical burden, quality of care, and organizational context are 3 different but related lenses that can be applied to optimize care for older people. In this issue of the Journal, Estabrooks et al4 reported on a retrospective analysis of longitudinal survey data from 36 Canadian nursing homes that examined the influence of organizational context on symptom burden in the final year of life between nursing home residents with and without dementia. The study symptoms are all commonly seen in nursing homes and include pain, behavioral disturbance, delirium, skin breakdown, dyspnea, and urinary tract infection (although strictly speaking this is more appropriately classified as a diagnosis rather than a symptom). The authors found that symptom burden increased as end of life approached, which is not surprising. They also discovered, however, that symptom burden differed between nursing homes with different modifiable features of organizational context. The findings suggested a possible nexus among symptom burden, quality of care, and organizational context. Health care systems are complex with multiple confounding components, and end-of-life care in the nursing home setting is no exception. The authors should be applauded for measuring modifiable components of organizational context. They deployed a tool that was developed locally, with reasonable psychometric properties in terms of validity and reliability. Whether the tool could be extrapolated more broadly in other jurisdictions remains to be seen.