This review cannot conclude which factors are more influential, and future studies are needed to uncover the reasons why some QIs have low pass rates. On the other hand, medication management and use, hearing loss and continuity of care, MK-1775 scored markedly higher than other conditions regardless of the setting and patient population and regardless of which QIs were used to assess them. This could be due to the increased attention to medication management in general, or partly attributable to chance due to the relatively low number of studies including these conditions. Although based on only one study, quality of care for falls in the hospital setting scored markedly higher than in other settings. This difference may be explained by fewer QIs being used in the hospital study and differences in the QIs that were used in the individual studies, or by increased attention to falls in hospitals and the more intensive care given to hospitalized patients compared to other settings. There was only one UK study in the primary care setting compared to three US studies. Although different QIs were used, the care for ischemic heart disease, diabetes, depression, hypertension, osteoporosis, urinary incontinence, stroke and vision care had better quality in the UK primary care setting compared to the US. It is plausible that this is due to differences in diagnoses and treatment of these conditions between the countries, or a different prevention program. This finding does not warrant general conclusions about the differences in quality of care between the countries, and more studies are needed. Although comparison of scores per setting was based on limited studies and QIs, it may reveal the need for extra attention to the conditions that form good candidates for quality improvement. These are the conditions that had mean scores below 50%. In managed care settings these conditions are: osteoarthritis, depression, urinary incontinence, falls, dementia, end-of life care, malnutrition, pressure ulcer care, and pneumonia care. In nursing homes, dementia, depression, diabetes, falls, stroke, ischemic heart disease, heart failure, osteoarthritis, osteoporosis, atrial fibrillation, vision and hypertension had consistently low scores. Finally, in primary care, dementia, UI, falls, osteoarthritis and vision care show room for improvement. According to the ACOVE indicators and the studies identified by our review, it appears that the quality of care for the elderly is low. However, we can only draw limited conclusions from these studies, for several reasons. First, although the QIs are generally evidence–based and have been developed in multiple Delphi rounds using expert panels, it is still possible that individual physicians will debate the content of specific QIs. Although the QIs are conjectured to represent minimal care, it is possible that low pass rates may represent legitimate differences of medical opinion. Second, undocumented patient refusal of the offered care could lead to a lower measured pass rate. Various studies, however, have taken this aspect into account and counted an indicator as passed when a patient refused the indicated care or when a contraindication existed.