This may come as a surprise to anyone who has found themselves at the mercy of our fractured healthcare system in recent years: Providers have been vigorously encouraged to improve the quality of care they offer. The results of the various edicts and guidelines passed down from public and private public health authorities since the early 1990s have been decidedly mixed — especially among vulnerable older adults.
For those patients, it’s not about doing too little. It’s about doing too much.
Prodded by strict quality-care protocols, practitioners in skilled nursing facilities (SNF) routinely deliver inappropriate treatments and prescriptions to ailing seniors whose life expectancy, frailty, and cognitive impairment call instead for a less aggressive approach. And, as geriatricians Joseph Ouslander, MD, and Michael Wasserman, MD, write in the Journal of the American Geriatric Society, this is especially common among those diagnosed with chronic hypertension and all forms of diabetes.
By some estimates, the incidences of hypotension (low blood pressure) and hypoglycemia (low blood-sugar levels) that result from overtreatment range as high as 40 percent of these older patients. “This translates into tens of thousands of emergency department visits and hospitalizations annually and results in excess morbidity, mortality, and healthcare costs,” Ouslander and Wasserman argue.
Chief among the forces that encourage providers to pursue an overly rigid treatment regimen despite an older patient’s vulnerability is a set of quality-care metrics that 90 percent of U.S. health insurers monitor closely to ensure their own financial viability. The Healthcare Effectiveness Data and Information Set (HEDIS), created in 1991 by the National Committee for Quality Assurance (NCQA), has become the leading performance indicator in the U.S. healthcare industry. It’s key to health-plan accreditation, Medicare ratings, and regulatory compliance.
Report a subpar HEDIS rating, in other words, and your bottom line could suffer.
The ratings are so influential, Ouslander and Wasserman note, that clinicians are forced to “choose between using a treatment that is no longer appropriate for the patient and can cause unnecessary and morbid complications on the one hand and achieving a high score on the [quality measures] on the other.”
HEDIS does include some exceptions in its guidelines for treating vulnerable seniors, but they require specific diagnoses and additional administrative documentation. And because the exceptions don’t apply to many patients, some physicians will refuse to handle these cases. “Clinicians can sometimes work around this conundrum,” the authors note, “but [quality measures] that do not incentivize inappropriate treatment would be a better solution.”
Citing data from a 2014 U.S. Department of Health and Human Services report, Ouslander and Wasserman note that more than one in five Medicare beneficiaries treated at SNFs suffered at least one instance of hypoglycemia due to overtreatment during the month they were surveyed. About 40 percent of those episodes were related to medications prescribed according to accepted industry guidelines. Extrapolating those results based on the estimated 1.5 million patients treated at SNFs, they conclude that more than 10,000 older adults would have suffered iatrogenic hypoglycemia in any given month.
More recently, a 2020 study of nearly 7,000 patients at Veterans Administration (VA) SNFs reported that more than 40 percent of those diagnosed with advanced dementia and limited life expectancy may have been overtreated for diabetes. And even when it became clear that these patients were being overtreated, physicians moderated the dosage in fewer than half of the cases.
Hypertension is even more common than diabetes among older adults, and the authors cite a litany of studies demonstrating the harmful effects — kidney failure, falls, and fractures — of overtreating high blood pressure among vulnerable seniors. One 2024 JAMA report tracking antihypertension treatment of nearly 30,000 VA nursing home residents over the course of 13 years found that it increased the risk of “severe, morbid, and costly falls, and other adverse effects” by as much as 140 percent.
I wouldn’t consider myself a vulnerable senior, but my own experience after a hypertensive crisis echoes some of those concerns. After running numerous cardiological tests in the emergency room, a doctor informed me that I would be prescribed lisinopril, a popular ACE inhibitor, to lower my blood pressure. When I queried her about the well-known side effects of this group of drugs and suggested maybe trying an ARB instead, she shook her head: “That’s not what the guidelines recommend,” she told me.
The drug, when paired with a calcium channel blocker, certainly did the trick; my blood pressure reliably descended into healthier territory and generally lingered there. But not long after I began taking the meds, I began to experience frequent bouts of peripheral neuropathy — a tingling and numbness all along the left side of my body. And as those episodes began to increase in frequency and intensity, I was forced to consider a tradeoff: less-effective blood pressure management or relief from an increasingly worrisome side effect.
Last week, while awaiting a refill of my lisinopril prescription — and noticing a slight easing of the neuropathic episodes — I emailed my doctor to suggest we discuss my medication at our upcoming visit. Her prompt reply was slightly surprising: “Lisinopril is not my favorite blood pressure medication,” she noted, recommending three ARB drugs. I chose one and picked up the meds the next day. Early results seem promising. No noticeable side effects.
I suspect Ouslander and Wasserman would be pleased.
“To truly protect vulnerable older adults from preventable harm, we must rethink how we manage chronic conditions like diabetes and hypertension,” Ouslander says. “This means moving beyond one-size-fits-all targets to evidence-based, personalized treatment plans shaped by shared decision-making, supported by appropriate technology, and backed by policies prioritizing patient safety over rigid metrics.”
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