Days Spent at Home

 

homeAn incredible amount of effort has been spent over the past decade in attempting to reduce the number of older patients who are readmitted to the hospital within 30 days. The argument is straightforward – readmissions are costly, disruptive for patients, and may represent insufficient coordination of care. While the proportion of readmissions that are truly preventable remains an area of active debate, readmissions are nonetheless a prime metric by which health systems are currently judged. Accordingly, many researchers (myself included) have published on factors associated with 30-day readmissions among older adults.

Recently however, the concept of “days spent at home” has emerged as a potentially more patient-centered goal. In an article in the New England Journal of Medicine, Drs. Groff and colleagues argue that this metric (initially inspired by the family member of a patient) may represent a closer ideal of what matters most to patients. This perspective makes sense to many of us in practice: while I’ve rarely had a patient tell me that what matters most to them is not being readmitted to the hospital within 30 days, they frequently tell me that what matters is spending time with loved ones, in a familiar environment. While the two concepts are related, “days at home” incorporates events beyond the hospital such as extended stays in skilled nursing facilities. It also provides important granularity – it is a continuous measure – rather than the simple “readmitted or not” paradigm that we have grown accustomed to.

Groff et al. conclude that “Outcome measures that reflect what truly matters to patients can define performance in ways that increase the engagement of patients, clinicians, and provider organizations in the redesign of care,” and I couldn’t agree more. A next critical step will be eliciting actual care preferences from patients in a formalized manner, and tailoring care plans towards these preferences. To date, studies have shown that many of these patients will likely prioritize spending days at home.

 

By: John Dodson, MD, MPH

Dyspnea: Listen to the Patient

dodson%20headshot“Listen to your patient; he is telling you the diagnosis.”
– William Osler

Dyspnea (the sensation of breathing discomfort) is a common and vexing problem among older adults: one review of the literature found that on average, 1 in 3 adults age ≥65 reported experiencing this symptom.

In addition to being common, dyspnea may portend a worse prognosis. Over 10 years ago, a study in the New England Journal of Medicine found that patients referred for cardiac stress testing who reported dyspnea had four times the risk of sudden cardiac death (compared with those who were asymptomatic), and were twice as likely to die as those with typical chest pain on exertion (median follow-up: 2.7 years). The authors concluded that dyspnea should be routinely evaluated before stress testing. A subsequent study in the PREMIER registry of patients with acute myocardial infarction found that dyspnea was common (present in nearly half of patients 1 month after an hospital discharge), and its presence was associated with impaired quality of life, hospital readmissions, and poorer survival compared with dyspnea-free patients.

It is unclear exactly why dyspnea portends such a poor prognosis. The authors of the New England Journal paper suggested that dyspnea may represent underlying ischemia, left ventricular dysfunction, of pulmonary disease. Alternate causes may include neuromuscular disease, cancer, anemia, or deconditioning. In my own practice, there’s often no single cause – an older adult with heart failure often has concurrent atrial fibrillation, lung disease, and deconditioning.

Similarly, it’s unclear how to optimally evaluate and treat many patients reporting dyspnea. Multiple specialists (cardiologists, pulmonologists, internal medicine) are frequently involved and may have conflicting recommendations. A centralized clinic to evaluate dyspnea (examples here and here) may help to relieve some of the patient burden of coordinating their own care between specialists. In addition, with the growth of goal-oriented care, relief of dyspnea may serve as a reasonable target around which to base therapies. At the very least, it’s clear that dyspnea in older adults should be routinely assessed, and if present should prompt further evaluation. In the setting of rapidly progressing technology in medicine, taking a good history is still paramount.

By: John Dodson, MD, MPH

Statins for Primary Prevention

dodson%20headshotA recent review article in JACC highlights the conundrum of primary cardiovascular disease prevention with statins among older adults. We often face this dilemma in our outpatient practices: specifically, whether patients age ≥75 without overt cardiovascular disease should be prescribed a medication to reduce their future risk, where the benefits of prevention may not accrue for several years. We are operating in a field with scant data: patients in this age group have been underrepresented in clinical trials showing benefit, and recommendations therefore need to be extrapolated from younger individuals. Accordingly there is a discrepancy in guidelines – while the UK NICE guidelines provide a strong recommendation for primary prevention statin therapy in this age group, other societies (ACC/AHA in the U.S., ESC/EAS in Europe) provide a weak recommendation, and the USPSTF in the U.S. provides no recommendation.

The authors highlight several issues to take into consideration when prescribing statins for primary prevention in this age group, including frailty, comorbidities, and polypharmacy (all of which may increase the risk of adverse drug effects), as well as limited life expectancy (which may prevent long-term benefits from accruing). They also discuss the importance of shared decision making with patients, taking into account their values and goals. Notably, statin decision aids already exist which may facilitate this process.

Several years ago we had written a piece on primary prevention for ACC.org which stated “statins are probably both under- and over-utilized in older adults,” and in my opinion this statement remains accurate. For an older patient who is functionally independent, with few life-limiting comorbidities and a strong desire to reduce their cardiovascular risk, a low to intermediate dose statin makes sense. For a patient with a major life-limiting illness, who wants to reduce their medication burden, it’s reasonable to not prescribe or even “de-prescribe” statins. Ultimately, the variation in guidelines described by Mortensen and Falk in their JACC article highlights that in the absence of consensus, care needs to be individualized – which is a central principle of geriatric cardiology.

 

By: John Dodson, MD, MPH

Glucose Monitoring in Older Adults: How Much Is Too Much?

Wilcox_TanyaMy 90-year-old grandfather was the first person to teach me how to use a glucometer. He developed diabetes thirty years after his 3-vessel CABG, and the necessity of daily blood glucose checks seemed like an inevitable aspect of managing his new disease. As a diligent patient, he underwent the painful experience of pricking his finger and recording his measurements daily, and taught me how to help him as he lost dexterity with age. The experience left me questioning whether glucose monitoring is necessary for all patients with diabetes, especially older patients with late-onset, stable disease like my grandfather.

Diabetes mellitus is common disease among older adults; in the U.S., 1 in 4 persons over age 65 are affected. Cardiologists recognize diabetes management as integral to overall cardiovascular health. However in older adults, aggressive glycemic control can be burdensome and at times dangerous. Evidence from large randomized control trials including ADVANCE, ACCORD and VADT suggests that avoiding dangerously low blood sugars (hypoglycemia) may be more beneficial than achieving aggressively low hemoglobin a1c (HbA1c) targets. Based on available evidence, the American Geriatrics Society recommends higher Hba1c targets for older adults –  between 7-8.5% depending on comorbidity burden and prognosis. There remains, however, a lack of strong evidence on the optimal frequency of home glucose monitoring in this group of patients. An individualized discussion the benefits, risks and alternatives provides a framework for this discussion.

There is a clear need to avoid hypoglycemia, and self-glucose monitoring may provide a mechanism to screen for low blood sugars. Accordingly, the Endocrine Society indicates that glucose monitoring may benefit type 2 diabetics taking medications that put them at risk for hypoglycemia, including insulin or sulfonylureas. This may be especially important during medication initiation or uptitration. However, in patients with stable disease with no clear risk for hypoglycemia, the Endocrine Society and the Society of General Internal Medicine both recommend against routine multiple daily self-glucose monitoring. Home monitoring is nonetheless overprescribed; CDC health behavior data indicate that a majority (63%) of non-insulin dependent diabetics are checking finger sticks at home at least daily, and Veterans Affairs data found that test strips were prescribed to a large number of patients with stable non-insulin type-2 diabetes. Potential harms associated with daily self-monitoring of blood glucose monitoring include pain of needle sticks, cost, and general therapeutic burden, all of which can adversely influence quality of life. While needle-free glucose monitors are a potentially promising alternative, they remain under development.

In summary, in the absence of clear guidelines, decisions about initiation, frequency and discontinuation of self-monitoring of blood glucose in older adults with type 2 non-insulin dependent diabetes requires an informed discussion between clinician and patient, with particular attention to patient goals. For most older patients with cardiovascular disease, in whom sulfonylureas should be avoided, routine glucose monitoring is reasonable for a brief period during medication titration, and subsequent intermittent monitoring may be helpful to determine whether symptoms of hypoglycemia correlate with low blood glucose. However, for most patients with stable disease on oral agents, discontinuing routine (daily) home glucose checks can improve quality of life and reduce health care costs.

 

By: Tanya Wilcox, MD

Improving the Patient and Family Experience: A Caregiver’s Perspective

authors.pngAs our country’s population ages at an unprecedented rate, we must be prepared to care for them, both as loved  ones/caregivers and health care professionals. For aging patients with chronic illnesses such as heart disease, this is particularly important. This topic impacted the two of us in a very personal way. Although we have spent both of our careers in clinical and leadership health care positions, we were stunned by events surrounding our patient with heart failure, as she was a beloved mother to one of us, and a sister and best friend to the other. The symptoms of her congestive heart failure came on suddenly and crept along forebodingly for a year and a half before the one-two punch came out of nowhere – a cardiac arrest while she was driving her car to a routine medical appointment. Miraculously, she was rescued and resuscitated by bystanders, including several physicians who happened to be nearby.

The seven months that followed were the most painful and difficult that we have ever experienced. Three cardiac arrests within 24 hours led to therapeutic hypothermia, extracorporeal membrane oxygenation (ECMO), left ventricular assist device (LVAD) implantation, tracheostomy, GI tube placement, and multiple complications including femoral hemorrhaging, GI bleeding, kidney failure, crippling deconditioning and serious infection after infection. During this time, she was shuttled back and forth between the ICU and a long-term acute rehab hospital. As we look back on that time through the lens of both healthcare professional and dedicated caregiver, we have identified a significant number of clinical processes and decisions that beg for improvements. Ultimately, she died not from her heart failure, but from a massive infection and septic shock, one of many complications that were a result of the extended amount of time that she was hospitalized and the expensive technology that initially saved her, if only for a few months. Our experience as her primary caregivers throughout her long and complex hospitalization, and the many system and process failures that occurred, have spurred us to communicate these issues in several formats, as well as seek to partner with healthcare organizations to improve the patient and family/caregiver experience. There are so many factors to consider when making health care decisions for our aging patients and family members, especially those with conditions that require costly treatments and interventions that cause complications that are equally as severe as the primary diagnosis itself.

These issues also underscore the importance of having a strong advocate at the bedside for those patients who can’t advocate for themselves, especially our compromised and/or elderly loved ones. Here are some of the key areas that we identified as needing improvement, and that an effective patient advocate must be prepared to address:

  1. Coordination of Care – The transition of care from one care setting to another is one of the most vulnerable points during a patient’s care, leading to quality and patient safety issues. During our sister/mother’s hospitalization, she experienced multiple transitions of care. We were alarmed at the lack of communication of critical information, as well as the absence of a coordinated plan of care between these care settings. We frequently had to step in and act as the care coordinator and educator, although we also found that many clinicians were initially reluctant to listen to us.The importance of the presence and active involvement of family members and other caregivers to a patient’s well-being and recovery cannot be underestimated. We are the people who know the patient most intimately, and can tell when something is not right. Most often, we are also present through the numerous physician visits and change of shifts, keeping track of changing and sometimes conflicting treatment plans, and alerting other clinicians to any issues.
  1. Shared Decision Making – With our sister/mother unconscious and on life support during her initial hospitalization, we were forced to make immediate decisions on life-altering procedures, such as putting her on ECMO to keep her alive until she could regain consciousness to participate in the decision to move forward with what was considered her only hope, an LVAD. Ginny knew from previous conversations that she did not want to consider an LVAD if her heart failure progressed, and we struggled with the decision. This was compounded by inadequate educational materials and pressure by the medical team to implant the LVAD, as they felt it was the only option. After taking a firm stance to wait for her to regain consciousness before we made these medical decisions without her, she awoke enough for us to convince the medical team to include her in the discussion, and she agreed to the surgery. However, looking back we realized how severely impaired her cognition and comprehension about her condition was at the time.Much work has been done recently on determining standards for decision aids to help inform patients of their options and help them take a more active role in decisions about their healthcare treatment options that reflect their personal goals. Research has shown that the use of these decision aids improves patient outcomes.
  1. Palliative Care – Patients must be fully informed of the pros and cons of any treatments, with palliative care offered as an option if appropriate. For patients with life-threatening conditions, such as our sister/mother, a discussion with a palliative care team to develop an Advanced Care Plan should have happened early on, and should have included a discussion about how her advance directives and preferences may change after having an LVAD implanted. As it was, we had to make the heart-wrenching decision to turn off her LVAD after she became comatose as a result of severe septic shock, with no chance of recovery – something we were not prepared for, and that had never been discussed with either her or any of us.

We hope that by relaying some of the challenges we faced during this extremely difficult time, we can help future patients and their caregivers enjoy a better healthcare experience, as well as assist healthcare providers to provide the safest, most efficient and dignified patient and family-centered care.

 

By: Melinda Kane, MS-HCM and Ginny Meadows, MSHI, RN-BC

 


Reference to our longer article: “Finding A Better Way” published in Circulation: Cardiovascular Quality and Outcomes.