Patient Priorities Care: State of the Art

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The Journal of the American Geriatrics Society published 3 related articles on redesigning healthcare around patient priorities, which I’ve linked to below. This work represents the leading edge of incorporating patient priorities into decision making for older adults. The rationale (previously discussed on this blog here, here, and here) is that for many older adults, the applicability of disease-specific guidelines are unclear; many of our therapies (in cardiology and elsewhere) were studied in relatively young patients with few comorbidities. In the setting of limited evidence, the concept of patient priorities care therefore emphasizes eliciting what matters most to patients – and designing care plans around specific, actionable goals.

Patient priorities care in practice is complex since it requires training of clinicians and support staff, engagement of patients, and streamlining of health information technology, all within our current time-limited healthcare environment. Nonetheless, the pilot studies by Naik et al. and Blaum et al. demonstrate that this care model can be effectively implemented in practice. The accompanying editorial by Applegate et al., which states that “Clinical guidelines could be revised to integrate the tradeoffs between multimorbidity, functional status, and polypharmacy in making management decisions” represents a longstanding principle of geriatrics which appears to be gaining traction in other fields (including cardiology).

Links below:
Naik et al., “Development of a Clinically-Feasible Process for Identifying Patient Health Priorities.”

Blaum et al., “Feasibility of Implementing Patient Priorities Care for Patients with Multiple Chronic Conditions.”

Applegate et al. “Implementing ‘Patient-Centered Care’: A Revolutionary Change in Health Care Delivery.”

 

By: John Dodson, MD, MPH

Hearing Loss and Heart Failure

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At first glance, hearing impairment and heart disease seem to have very little in common. However, the relationship has been hypothesized since the 1960’s, and more recently has been established in epidemiologic studies – with a particular emphasis on heart failure. For example, a recent study by Sterling et al. examined patients in the cross-sectional NHANES Survey aged ≥70 years with a diagnosis of heart failure. The authors described the percentage with quantifiable hearing loss based on pure-tone audiometry (considered the gold standard test).

The main findings: 74% of patients with heart failure had some degree of hearing loss, which was significantly higher than those without heart failure (63%). Further, only 16% of heart failure patients wore hearing aids. Thus there was a disconnect between the burden of hearing loss, and use of a strategy (hearing aids) with proven effectiveness.

Why does this matter? According to the authors: “since patients with HF [heart failure] are frequently in noisy hospitals and clinics where they receive myriad instructions about disease management, it seems likely that untreated hearing loss could impair patient-physician communication and ultimately HF self-care.” After my recent two weeks attending on the inpatient cardiology service, I concur. We are constantly expecting our patients to provide us an accurate history, comprehend diagnostic test results, and adhere to discharge plans, all of which may be affected by hearing impairment.

What are the solutions? The first is to increase identification of hearing impairment through screening – and with advances in technology, I’d predict this can soon be easily done at the bedside with portable electronic devices. The second is to make hearing aids more accessible, including over-the-counter purchases – and recently there has been some notable advocacy work advancing laws to increase access. Through these two simple strategies, we may be able to make meaningful improvements in the health of our older cardiac patients.

Compassion in Medicine

cherylThe aging hearts of our loved ones are multifaceted for sure. Kind, funny, witty, intelligent, brave, accomplished, and if we’re lucky, loving with a lifetime of experiences all wrapped up into a well-lived life. Certainly a life deserving of respect, all the best medical care, compassion, understanding, and help to navigate this final stretch of the journey.

My mother was fiercely private concerning her medical care.  She did not want anyone, other than my father, to know what doctors she was seeing and why.  When it became obvious to my (physician) husband and I that her condition was deteriorating, stepping in became a delicate balancing act.

My final journey with my mother began over two years ago when I noticed she was exhausted much of the time and her breathing was labored.  My husband spoke to me about his concern in private, knowing to tread lightly.  Whenever either of us asked her how she was doing, and expressed concern, she very firmly stated that nothing was wrong.

When she began having difficulty with memory and recall, she reluctantly agreed to see a neurologist friend of ours.  After testing, he concluded she was experiencing normal progression in aging. Her energy level, however, continued to decline.  She assured us again that she was fine and was seeing a cardiologist for chronic A-Fib, which my father confirmed.

A few months later she ended up in the local emergency room, the result of a fall. Although her cardiologist had an office in the same hospital, we discovered that his records were not linked to the hospital system.  Consequently, the ER doctor, not having the cardiologist’s records on my mother, took her off blood thinners because she felt the risk of injury from fall was greater than the benefit of my mother remaining on her medication.  This likely contributed to the further significant decline of my mother’s condition.  When my husband discovered her medication had been stopped he had my father call their cardiologist immediately to correct. We encouraged my father from that point on to keep a physical copy of their medical records with him for every future trip to the hospital and doctor’s office.  Unfortunately, not every patient has the luxury of having a physician in the family.

Sadly the other effect (we assumed of the fall) was significant cognitive impairment. When re-examined by her neurologist, she had declined drastically. He secured and poured through all of her medical records.  He found she had been diagnosed with mitral stenosis and severe pulmonary hypertension years before which were contributing to her confusion.

Together, my father and I decided that I would be included in Mother’s next cardiologist appointment.  Given her condition I stated at that visit that we would like her to see an Interventional Cardiologist.  I’ll admit I was a bit skeptical before meeting this new doctor, as all we were offered to this point was monitoring.  When Dr. K walked in, he was extremely welcoming and respectful and had actually taken the time to read Mother’s chart before meeting with us—this was a first!  He was very kind and honest from the start.  He told us she actually had Rheumatic Mitral Stenosis and that he could offer a procedure called valvoplasty.  This procedure could potentially give my mother great quality of life for her remaining years.

Being a teacher, I appreciated his unique ability to explain this complex diagnosis and procedure in terms my parents and I could understand.  And, he took as much time as we needed to feel comfortable with the next step.  Dr. K had given us so many gifts that first day.  His world-renowned expertise, his genuine kindness and caring, gave us hope for the first time in years.  He also gave us his cell phone number in case we had any questions or concerns.

Although blood clots ultimately prevented my mother from receiving this procedure, Dr. K’s care did not end there. He took time out of his busy schedule to meet with our family and discuss how best to care for Mother. He set into action Home Healthcare, having a nurse perform home visits and enabling him to monitor her INR. He even discussed (in person, by phone, or by text) when to get Hospice involved, end-of-life decisions, and what my father could expect every step of the way.

Everything Dr. K did enabled my mother to have the best quality of life possible, to live out her final days as she wanted to.  My mother was a woman of deep faith. She was not afraid of dying. Quite the opposite, she knew Heaven was her ultimate destination. It was her wish to remain in her home, and she did.  She was able to live out her final days in the home she loved, with the people she loved, and in her words, “with the best husband I ever could have asked for” for all but her final six hours.

When Dr. K learned of my mother’s passing, he asked to meet with my father and myself.  When we met we were yet again amazed. His mission was to share a cappuccino and make sure we were doing all right.  Talk about a lesson in compassion… I feel it is worth mentioning that although Dr. K was the newest cardiologist on my mother’s case, he was the only doctor to follow us through her death.

Lessons learned on the journey:

  1.  The best way to preserve a loved one’s dignity is to be their advocate.
  2.  Always be respectful but get involved as needed.  Get referrals, go to appointments, ask the difficult questions so your loved one has all the information necessary to make their decision.
  3.  I always knew and respected the fact that the final medical care decision would be my mother’s and father’s to make.  Even if the decision was no further procedure.
  4. My role was to connect my loved ones to the best possible medical specialists.
  5.  There simply are no words to adequately thank someone for giving you more quality time with your loved one.  I am eternally grateful to Dr. K and the other doctors on my journey who truly care for their patients and families.

 

By: Cheryl Csorba

 

RUSK Insights Podcast Series: Geriatric Cardiology

Screen Shot 2018-07-13 at 1.42.24 PMI recently was interviewed by Dr. Thomas Elwood for the NYU Langone Rusk Podcast Series, available here. I’d encourage people to listen to both sessions; Dr. Elwood asked a wide range of detailed questions relating to Geriatric Cardiology both locally and nationally. Here are a few key points:

  1. Geriatric cardiology is a growing field. Geriatric cardiology has emerged in response to an aging population coupled with advances in cardiovascular therapies. Several programs have been started in the U.S. in the past several years, most combining both patient care and research components.
  2. Frailty is a strong predictor of adverse outcomes in myocardial infarction. Multiple studies have shown frailty, a state of increased vulnerability to physiologic stressors, to be associated with both immediate consequences (procedure-related complications) and long-term sequelae (recurrent myocardial infarction, mortality). The optimal management of frail myocardial infarction patients remains unclear.
  3. Older adults are frequently excluded from clinical trials. While this is improving, thanks to the efforts of funding agencies, patient advocates, and the research community, we’re still largely operating in the dark when it comes to applying evidence-based therapies to patients in their 80’s and 90’s.
  4. Family caregiving is more critical than ever for recovery. As we move towards shorter hospital stays and lower use of skilled nursing facilities, we are asking a lot more of family members than we used to during the early recovery phase. This can lead to both physical and emotional burdens on these caregivers, which the healthcare system is currently under-equipped to address.
  5. There are multiple barriers to cardiac rehabilitation in older adults. These include transportation, cost, and lack of available facilities. Mobile health (mHealth) strategies may provide a means to increase access, but the efficacy of these programs in older adults remains poorly understood.

 

By: John Dodson, MD, MPH

Cognitive Screening in Heart Failure

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Photo Credit: APA PsycNET

Cognitive impairment, which includes deficits in memory, language, concentration, and reasoning, is common and often unrecognized in older patients. As a trainee, one of my first projects was to work on a study that performed cognitive assessments in a series of 282 patients age >65 hospitalized for heart failure. We found that cognitive impairment was common – present to some degree in nearly half of patients – and documented by physicians in fewer than one-quarter of cases. Further, we found that cognitive impairment was associated with mortality or hospital readmission within 6 months – and that patients with impairment that was not documented by physicians constituted the highest risk group. Our findings mirrored previous studies (examples here and here) documenting the common co-occurrence of cognitive impairment with heart failure.

Translating findings like this into actionable clinical practice can be challenging, but some centers are starting to routinely incorporate cognitive screening into care. Cleveland Clinic, for example, has published findings from screening using the Mini-Cog (a simple test that involves 3-item recall and a clock drawing task) and found that an abnormal test result (indicating cognitive impairment) was the strongest predictor of readmission among 55 candidate variables. They subsequently published a protocol for training nurses to use the Mini-Cog in practice in order to facilitate implementation among clinical staff unfamiliar with the instrument.

When cognitive impairment is discovered, there’s no easy solution to management – but several strategies make intuitive sense. Involving family members more closely in caregiving — to remind patients of their appointments and to assist with medication management — may help to avoid problems related to nonadherence (for example, hospitalization for decompensated heart failure). In my own practice, I try to simplify medication regimens whenever possible in patients who are cognitively impaired, with the goal of improving adherence and avoiding adverse medication-related events. Finally, since cognitive impairment has many causes, referral to a memory center can help to establish a formal diagnosis and set expectations in terms of what to anticipate in the coming years.

 

By: John Dodson, MD, MPH

Shared Decision-Making in Acute Myocardial Infarction

Headshot_Grant_2018Several weeks ago I had the pleasure of presenting our findings from a qualitative research study we conducted at the AGS 2018 annual meeting, investigating cardiologists’ perspectives and familiarity with shared decision-making (SDM) in older adults after hospitalization for acute myocardial infarction (AMI). SDM has emerged in the literature as a way to move towards patient-centered care and has significant potential to enhance patient adherence, reduce undesired treatments, and improve overall satisfaction with care. In our study, we sought to discover the degree to which practicing cardiologists understood SDM, and whether it was applicable to their practice with older adult patients – particularly in the setting of cardiac catheterization and percutaneous coronary intervention. Five major themes emerged from these interviews:

  1. Age alone is not a major contraindication to intervention.

Our respondents consistently stated that age would not deter them from sending a patient to cardiac catheterization. Instead, they generally brought up “what kind of 80,” distinguishing chronological and biological age. Further, cardiologists generally reported treating older adults similarly to how they would treat their younger counterparts.

  1. SDM is important in the setting of NSTEMI, and not practical in STEMI:

Respondents felt that SDM was useful among patients hospitalized for NSTEMI (who represent the largest proportion of older adults with AMI). Conversely, due to the acuity of STEMI (with system-wide pressures on prompt reperfusion therapy), there was near-universal agreement that SDM was not practical in this setting.

  1. Dementia and functional status emerged as the major contraindications to intervention:

While age was not itself a major contraindication to intervention, age-related impairments such as dementia and functional status were consistently noted as reasons cardiologists would adopt a more conservative approach to care.

  1. There was some variation in cardiologists’ interpretation of SDM:

While most cardiologists saw SDM as a move away from paternalism towards patient-centered care, there was some variation in what the meaning of “shared” was among our respondents. While some respondents felt it was shared between the cardiologist and her patient, others thought it was between the patient and family members, and still others thought it was between the provider and her colleagues.

  1. A personalized (and geriatric-informed) risk calculator may help to facilitate SDM in this population for cardiologists:

Cardiologists continually highlighted the paucity of data to guide their care in the older adult population, and emphasized that a risk calculator tailored to these patients would allow them to give more specific and personalized information in order to promote SDM with accurate calculations of risk and benefit.

Our findings have several implications. The take-home message was that cardiologists generally accepted SDM as an optimal model of care, particularly in settings where the risk/benefit ratio was uncertain, but experienced some challenges with accurate prognostication. Future efforts at personalized risk calculators, tailored to older patients’ phenotypes, may help to promote SDM in practice.

 

By: Eleonore Grant, BA

Eleonore Grant was an Associate Research Coordinator at NYU Langone Health and coordinated studies on shared decision-making. She will be matriculating at medical school this Fall. 

Hospital at Home

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                                                                                                                                   Photo credit: Shutterstock

Last week marked the annual American Geriatrics Society (AGS) meeting which brings together geriatricians and other healthcare professionals (including a growing contingent of geriatric cardiologists) to highlight the latest in research related to caring for older adults. One of the highlights was the Henderson Lecture, given by Dr. Bruce Leff (Johns Hopkins) on the future of healthcare for older adults moving out of the hospital and into the home. The general concept is that the hospital can be a disorienting environment for older adults, and there are concomitant risks (including hospital-acquired infections, falls, delirium, deconditioning due to immobility) that may be reduced by providing acute care at home. Concomitantly, cost pressures are leading health systems and insurers to think of more “out of the box” solutions to avoid the high costs associated with traditional hospitalizations.

Data on hospital-at-home models have been encouraging. For example, a meta-analysis of over 60 clinical trials in 2012 demonstrated hospital-at-home led to reduced mortality, hospital readmission, and cost. The potential mechanisms are clear: a familiar environment reduces the risk of delirium, which has multiple adverse consequences. Opportunistic infections are much less likely. Family caregivers are more immediately available to provide comfort.

Conversely, it’s clear that many of today’s hospitalized patients are too ill (and at high risk for decompensation) for acute medical care to be safely delivered at home. Within cardiology, this includes conditions that are procedure-intensive (acute myocardial infarction) or require high-level monitoring (cardiogenic shock, unstable arrhythmia). But I think many other acute cardiovascular conditions common in older adults could be managed with reasonable ease at home (mild decompensated heart failure comes to mind), provided adequate resources. Barriers to more widespread adoption of home-base models include payment for these programs (currently a work in progress), as well as the logistics of providing equipment (Dr. Leff noted in his lecture how difficult it was to deliver something as simple as oxygen).

Nonetheless, the paradigm holds considerable promise, and I’d expect health systems to adopt more of these programs in the next 5-10 years. If nothing else, changing demographics (specifically the aging of the U.S. population) will demand more innovative solutions like this.

 

By: John Dodson, MD, MPH