I recently received a text from my friend asking, “Should my dad be on Lipitor? His cardiologist hold him that all of his numbers looked good. And at the end of the visit, they told him that he should start taking Lipitor. Seemed kind of like as an afterthought as he was walking out the door.”
It’s an incredibly common situation: a doctor recommends a statin and a patient wonders whether any thought when into the decision at all. After all, doctors often say, “everything looks good” when things are suboptimal as long as there isn’t anything that puts you in imminent danger. Plus, it’s easier to just tell someone that they need to be on a medication than to counsel them about their individual risk factors and how best to modify them?
This decision is generally straightforward if you’ve had a heart attack – being on a statin is probably the right choice.
But for preventing a first heart attack? It’s a more difficult decision and one that’s fraught with a lot of misinformation as well as doctors who don’t interpret cholesterol panels with depth or nuance (or more importantly, don’t order the correct tests to begin with).
Wrong decision making goes in both directions here – there are a lot of people who are taking statins who do not need to be on them and a lot of people who should be on them that aren’t taking them.
How do we think about risk?
There are a number of standard heart disease risk factors that every doctor looks at – blood pressure, blood sugar, cholesterol, family history, smoking, obesity. Some of these are modifiable through lifestyle choices and some are not.
There are also a number of non-standard risk factors that we evaluate – metabolic syndrome, chronic kidney disease, autoimmune disease or chronic infection (diseases with increased inflammation), lipoprotein (a), premature menopause, and preeclampsia.
Huge amounts can be written on all of these individually, but I think that most of the medical decision making (and personal decision making!) about what to do boils down to the decision my friend asked me about above – should you be on a statin?
Statins are the most prescribed drugs in the world and Lipitor (atorvastatin) alone has made Pfizer almost $100 billion in revenue over the past 20 years. Even now that Lipitor has been off-patent for 8 years, it still generates $2 billion a year in revenue.
The numbers are insane. I suspect the fact that there are so many people prescribed statins who haven’t manifested heart disease helps to explain the proliferation of skeptics about their widespread use.
The ways we measure risk are imperfect
We use a few different methods to attempt to quantify a patient’s individual cardiac risk. There are a number of calculators that can be used to calculate approximate 10 year cardiovascular risk – meaning estimate your chance of having a heart attack over the next 10 years.
There’s one from the American Heart Association and American College of Cardiology (AHA/ACC). There are other ones based on large cardiovascular clinical trials such as the Multi Ethnic Study of Atherosclerosis (MESA) or Framingham.
While these are great for predicting risk across a population, they miss a lot of important aspects of individual risk. None of them incorporate all of the factors that increase your own personal risk. We certainly have a good sense of accuracy on the very high end and the very low end, but it’s the folks in the middle where the risk stratification becomes less reliable.
And when you’re thinking about taking a medicine everyday indefinitely, you really want information to personalize your own risk.
So when I’m talking to my patients about this decision – the ones who haven’t had a heart attack but may have some risk factors – I generally recommend additional individualized stratification.
A coronary calcium score is a great tiebreaker for this decision
A coronary artery calcium (CAC) score is a low radiation CT scan that lets us look to see if there is any calcium built up in the arteries around the heart.
You may have heard the term “hardening of the arteries” before. That’s calcification.
Any calcium in the coronary arteries – that is, a calcium score of any number over 0 – implies heart disease is present. Of course, there is a gradation in risk based on the amount of calcium (hence, calcium score), where higher numbers = greater risk.
CAC is better at reclassifying someone’s risk as either low (maybe ok to hold off on meds) or high (maybe it’s time to start something) than any other test that we have. Since it provides quantitative information about your own cardiac anatomy, this test can help to frame your own personal risk-benefit analysis.
So back to my friend’s question, “should my dad be on a statin?”
The answer is: it depends on a lot of factors – your own values and risk tolerance as well as all of your biomarkers and family history – but getting a coronary artery calcium score is a helpful piece of figuring out your own personalized risk.
By Gregory Katz, MD
This post originally appeared on gregorykatzmd.com on 07/15/2020.
A recent piece in JAMA Internal Medicine by Roberts and Mehrotra underscores that even in our connected age, many older adults have difficulty accessing technology. While telemedicine has been widely deployed in the setting of COVID-19, these individuals are therefore unable to achieve many of its benefits. Their main findings, in a survey of 638,830 Medicare beneficiaries, were the following:
– Over 40% lacked access to a desktop or laptop computer with high-speed internet;
– Similarly, over 40% lacked a smartphone with wireless data plan;
– Over 1 in 4 people (26%) lacked both (no computer or smartphone);
– Digital access was lower among people age 85 or older, and among those who were widowed, had lower education, were Black or Hispanic, received Medicaid, or had a disability.
Their findings are in line with my own clinical experience over recent months – while telemedicine has provided a critical way to maintain care for some patients, others are simply unable to engage. Related to the work by Roberts and Mehrotra, we published a recent piece in JAMA Health Forum outlining how “digital health” may actually worsen health disparities – if adopted by younger populations who are already reasonably healthy. Both articles underscore that patients most at risk for poor health outcomes are also the least likely to have access to the new era of digital medicine. While improving digital access among these populations is challenging, it is also essential.
By: John Dodson, MD
In our article recently published in Medical Decision Making, we qualitatively explored the experience of shared-decision making (SDM) in the setting of acute myocardial infarction (AMI), from the point of view of both cardiologists and patients. We conducted 20 interviews with older adults (age ≥70) who had been hospitalized with AMI, and 20 interviews with cardiologists. Six major themes emerged from our analysis:
1) patients felt their only choice was to undergo an invasive procedure;
2) patients placed a high level of trust and gratitude toward physicians;
3) patients wanted to be more informed about the procedures they underwent;
4) for cardiologists, age was not a major contraindication to intervention, while cognitive impairment and functional limitation were;
5) while cardiologists intuitively understood the concept of SDM, interpretations varied;
6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI).
Our most salient finding was that patients felt they had no choice but to undergo intervention, whereas cardiologists stated there was a need for deliberate shared decision making about intervention in older adults with NSTEMI because of the increased risks involved with catheterization in older patients who present with greater comorbidities.
This discrepancy suggests that, from the patient perspective, conversations in practice were often inadequate to be fully informational. Solutions to this shortfall are complex, especially in light of time constraints in current inpatient settings. However, we suggest in our article that a decision aid may help to provide standardized information to patients, as well as individualized risk prediction (e.g., for risk of contrast-related acute kidney injury). This may alleviate some of the stress and uncertainty involved in discussing evidence-based risks for physicians, and it could increase patients’ awareness of a choice.
Our study had several limitations, including the typical bias in research studies of enrolling “healthier” participants (e.g. cognitively intact) who may have had the most to gain from an intervention. Moreover nearly all patients interviewed underwent invasive coronary angiography (rather than conservative management with medications alone), which omits the decisional needs of patients who chose to decline the procedure. This finding likely reflects a combination of institutional practice, national trends toward more invasive procedures in older adults, and selection bias.
Despite these limitations, to our knowledge this is the first study of SDM in the setting of AMI that incorporates both patient and cardiologist perspectives. We hope (1) it highlights the importance of capturing this dual perspective when discussing SDM and (2) SDM can be made more effective for older adults with NSTEMI with the implementation of a decision aid to help physicians faced with a lack of clear evidence for this older population, and patients who may benefit from being more informed.
By Eleonore Grant, MD Candidate 2022
Perelman School of Medicine at the University of Pennsylvania
The past month has been a crash course for me in telemedicine, as my geriatric cardiology practice went from fully in-person to fully “virtual” in light of the COVID-19 pandemic. Despite the abrupt startup and inevitable bumps along the way, many of my older patients have successfully transitioned to video encounters for the time being. And I’ve noticed a recurring theme during many of these video conversations: people tell me that they’re terrified of coming to the hospital, even in an emergency.
This fear has been reported in both the scientific literature and the lay press – with a precipitous drop in hospitalizations for emergent conditions ranging from acute coronary syndrome (ACS) to stroke. For example, Metzler et al. reported that in Austria, from the beginning to the end of March 2020, ACS hospitalizations decreased by nearly 40% – far outside the range of normal variation. The authors hypothesized that “the strict instructions to stay at home as well as the fear of infection in a medical facility may have…prevented patients with an ACS from going to a hospital.” Similarly, a study in the U.S. of several high-volume cardiac catheterization laboratories found a 38% reduction in emergent activations for ACS due to ST segment elevation myocardial infarction after March 1. In the setting of ACS, failure to present due to fear of hospitals may lead to multiple consequences including fatal arrhythmias, heart failure, and death. And based on the data, it’s highly likely that many patients are suffering through ACS and other emergent conditions at home.
What steps can we take? COVID-19 has created an unprecedented challenge to modern healthcare, and there’s no consensus even among experts. In my own practice, I emphasize to my patients there are certain symptoms – persistent chest pain, shortness of breath at rest, new speech difficulty – that require them to go to the emergency room; the consequences of failing to act are too great. Letting patients know about new telemedicine options (e.g. virtual “urgent care” 24 hours a day) may help them to know there are options between staying home and calling an ambulance, so that their symptoms can be appropriately triaged. Finally, as the effects of social distancing take hold and COVID-19 cases decline, fear of hospitals may decrease. But for now, the problem is very real, and can be considered as one of the many negative consequences of the pandemic.
By: John Dodson, MD
On March 11, 2020 the World Health Organization declared COVID-19 a global pandemic. SARS-CoV-2, the virus that causes COVID-19, was initially recognized in China in December 2020 then over the course of three short months has brought the hustle and bustle of NYC to a grinding halt. Terms such as “social distancing”, “flattening the curve”, and “hydroxychloroquine”, are now spoken causally in everyday conversation. The rapid evolution and spread of the virus has been accompanied by a mounting body of experimental protocols aimed to treat those infected, a large proportion who are over the age of 65.
One such treatment protocol is the use of azithromycin and hydroxychloroquine to treat symptomatic hospitalized patients with supplemental oxygen requirements. This treatment strategy is currently off label and is based on a small French study showing decreased viral burden. Additionally, the use of hydroxychloroquine alone is based on limited data including a study showing inhibition of the virus in vitro, meaning in the laboratory. These off label treatments, based on limited evidence, are being widely used across the United States to treat patients hospitalized with COVID-19. While there is hope for benefit, there is also potential harm due to adverse drug events, especially in older adults. While large randomized trials of these medications will provide definitive evidence, they will also require more time.
In those age 65 years and older it is necessary to critically examine the potential deadly cardiac side effect commonly known to be associated with azithromycin and hydroxychloroquine, QTc prolongation. This prolongation can lead to deadly ventricular arrhythmias. The QTc is the QT interval on an ECG corrected for heart rate. Studies have shown that, as chronological age increases, so does the QTc interval. Theories for this phenomenon include increased myocardial fibrosis altering the myocardium and changes to the sympathetic and parasympathetic tone effecting myocardial repolarization. This can result in increased susceptibility to events and medications, which may further prolong the QT interval.
Figure 1. ECG Phases
Recently the Canadian Heart Rhythm Society published a treatment guideline aimed to minimize the risk of drug-induced ventricular arrhythmias. The article acknowledged that the use of certain antimicrobials to treat COVID-19 has uncertain benefits but may increase the risk of QT prolongation. They proposed an algorithm that included obtaining a baseline ECG and electrolyte panel, as well as a subsequent ECG 48 hours after initiation of therapy. The guidelines recommend that QT prolonging antimicrobial agents should generally be stopped in the setting of a QTc >500. An article in press from investigators at the Mayo Clinic makes similar recommendations.
The rapid spread and deadly devastation of COVID-19 has resulted in clinical momentum to find a definitive treatment. However, combining two medications, azithromycin and hydroxychloroquine, in the off label treatment of COVID-19 and administering them to a vulnerable patient population must be performed with extreme caution, even if the risk to the general population is low. We must continue to uphold the principles of evidence-based medicine even in a time of a global pandemic.
By: Megan E. Rau, MD, MPH
Dr. Rau is a practicing physician at NYU Langone Health who specializes in geriatrics and palliative care & hospice.
Ask any older adult about their preferences for end-of-life care, and the majority of them will tell you that they would prefer to die at home rather than in a hospital. Unfortunately, this desire is often not fulfilled.
The population in the United States is aging; by 2030, 1 in 5 Americans will be over age 65. This shift in demographics has already had a significant impact on healthcare utilization, particularly in regard to emergency medical services. Not only do older adults visit the emergency department (ED) at higher rates than younger patients, but they are also more likely to be admitted and experience longer stays.
These trends are especially prominent near the end of life, with half of older adults visiting the ED within the last month of life. For those older patients who are discharged home from the ED, repeat visits are common. This often results in a vicious cycle in which older patients are repeatedly discharged home from the ED, only to return within a few months, often for the same diagnosis that brought them to the ED in the first place. Notably, there are few safeguards in place to reduce recurrent ED visits.
With the passage of the Affordable Care Act in 2010 came the Hospital Readmission Reduction Program, which allowed Medicare to reduce payments to hospitals with excessive readmission rates. As a result, hospitals created programs to reduce readmissions, such as arranging for outpatient follow-up before discharge. However, such initiatives are only available to patients who are admitted to inpatient services and do not exist for patients who are discharged home from the ED. Thus, the ED represents a pivotal point in which clinicians can intervene to improve end-of-life care and reduce recurrent ED visits among older adult patients with advanced illnesses. The question then becomes: what should those interventions be?
Utilizing the ED as a means to enroll patients in palliative care programs represents a paradigm shift that may support older adults with advanced illness and repeat ED presentations. Palliative care is a rapidly growing field that is designed to provide supplementary care to patients with serious, life-limiting illnesses by providing medical, social, and emotional support to patients and their caregivers. Importantly, palliative care does not depend on prognosis and may be delivered in conjunction with life-prolonging treatment.
Multiple studies have shown that palliative care improves quality of life among patients and their families, lessens symptom burden, reduces future ED visits, and helps patients achieve their end-of-life goals (as evidenced here and here). Further, when the American Board of Emergency Medicine officially recognized palliative medicine as a subspecialty in 2006, palliative care found a new role within the ED. As a result, there has been a surge of research regarding the benefits and feasibility of palliative care in the ED, as well as the best ways to design programs and educate providers.
Although the benefits have been well established, there are also significant barriers to implementing palliative care in the ED. Patients in the ED, particularly those in need of palliative care services, are often distressed and may not be receptive to discussions regarding end-of-life care. Additionally, some ED physicians may feel that palliative care is outside the scope of their practice. Others worry that the chaotic environment in the ED is not conducive to meaningful end-of-life care discussions, and that implementing palliative care in the ED may significantly impact wait times.
In spite of these barriers, frequent repeated ED visits are likely to become more common with the aging U.S. population, and initiating palliative care in the ED has the potential to improve care for older adults in several ways: by decreasing repeat ED visits, improving quality of life, and helping patients achieve their end-of-life goals. Future implementation science efforts may help to identify optimal strategies to deliver palliative care in the fast-moving and often disruptive ED environment.
By: Julia Allison Brickey
Julia Allison Brickey is a medical student at the University of North Carolina School of Medicine.
My 83-year-old patient had outlived peoples’ expectations on several occasions. Faced with a critical illness three years ago, she underwent emergency surgery and spent several months in the hospital with a series of complications, including septic shock, renal failure, and hospital-acquired pneumonia.
I’d seen her in the office for a new visit soon after she was discharged. It took nearly 20 minutes to go through her history before walking into the exam room. Notes from several doctors during that hospitalization said that she might never become well enough to be discharged home. When I finally walked into the room, I expected to see someone frail, debilitated, with a caregiver answering most of my inquiries. Instead, she appeared robust, completely alert, and cheerfully answered my questions herself. “You look better than your chart,” I told her, truthfully.
Given the extent of her recent workup, we agreed to keep further testing and medication changes to a minimum. I established that we’d touch base in the office every three to four months — a typical interval at her age.
And somewhat to my surprise, over the next several years she maintained her independence, as well as her cheerful demeanor. While she did experience some setbacks — a hospitalization for pneumonia, or mild volume overload — she usually made it home within a week.
The last time I saw her in clinic was different. She had been hospitalized for nearly a month, with a series of problems including a declining ejection fraction, rising creatinine, and multiple infections. In my interview, she looked more fatigued and responded only in brief sentences. She had lost considerable weight and had difficulty walking. I knew from a growing body of research that these last two findings were very poor prognostically in her condition.
In this context, I suggested initiating home hospice. I explained that this would provide her with a visiting nurse, medications to alleviate her symptoms, and a general focus on keeping her out of the hospital. I also explained that I expected her survival to be less than six months. After a lengthy discussion with my patient and her caregiver, she agreed.
The following week, the hospice nurse visited her at home for an intake visit, and she sent them away.
This experience is not unique. Studies show that some patients with advanced illness are unwilling to use hospice. Further, even among those who initially agree, many reverse the decision when their condition worsens. A paper earlier this year by Russell and colleagues found that 30% of patients with heart failure on home hospice in New York City ultimately canceled hospice, most often because of worsening symptoms that led to an acute hospitalization. This process, termed “live discharge from hospice,” is over twice as common with heart failure compared with cancer.
The phenomenon may stem, in part, from the “peaks and valleys” characteristic of advanced heart failure, which stand in contrast to the slow progressive decline of metastatic cancer or dementia. Heart failure patients can experience dramatic improvement with a short course of intravenous diuretics — which relieve symptoms without influencing the long-term disease course.
And perhaps my patient was not ready to let go of the hope that this time, like many times in the past, she would improve. As her cardiologist, I also had to let go of my own notions about what was best in her condition. While my clinical experience informed me that her prognosis was poor, this was ultimately her decision to make.
Within one month, my patient was admitted again to the hospital with shortness of breath and was found to have progressive heart and renal failure. I was away at the time.
The inpatient team and her indefatigable primary care physician had multiple discussions with my patient and her (also indefatigable) caregiver about her condition.
They set expectations, given what was known about her disease, and she set dual goals of symptom relief and avoiding another hospitalization. After one week in the hospital, she was referred home with hospice, and this time she did not send them away when they visited. She was ready. Several days later, she passed away, supported, at home.
By: John Dodson, MD
Sex differences between younger men and women presenting with acute myocardial infarction (AMI) have been recognized for decades. Whether sex differences persist among older adults (≥75 years old) with AMI, including in their relative burden of functional impairments, has not been adequately studied in a contemporary older adult population. Given this uncertainty, we set out to assess sex-based differences in presentation characteristics, functional impairments, in-hospital treatments and complications, in older adults ≥75 years presenting with AMI from the SILVER-AMI study. We recently published our findings in Circulation: Cardiovascular Quality and Outcomes.Some key highlights:
- Among 3041 participants in SILVER-AMI, women and men differed across many baseline and presentation characteristics. Women had lower rates of prior coronary disease and, among those with non-ST-segment-elevation MI (NSTEMI), reported chest pain as their primary symptom less often than men (50.0% vs. 58.6%).
- Older women with AMI had higher rates of age-associated functional impairments at baseline than men, including higher rates of cognitive impairment (NSTEMI: 20.6% versus 14.3%; STEMI: 20.6% versus 12.4%), impaired functional mobility (NSTEMI: 44.5% vs. 30.7%; STEMI: 39.4% vs. 22.0%) and disability with activities of daily living (NSTEMI: 19.7% vs. 11.4%; STEMI: 14.8% vs. 6.4%).
- Women had lower rates of obstructive coronary disease and underwent less revascularization than their male counterparts in both the ST-segment-elevation MI (STEMI) and NSTEMI groups.
- Bleeding complications were more frequent among women with STEMI (26.2% vs. 15.6%), driven primarily by higher rates of nonmajor bleeding (20.4% vs. 11.5%) and bleeding following percutaneous coronary intervention (PCI) (22.6% vs. 14.8%) among women.
The higher rates of functional impairment among older women identified here underscore the importance of assessing all hospitalized patients for impairments associated with aging, with an especially high index of suspicion when caring for older women with AMI. Improved diagnosis can help guide interventions to optimize mobility, adherence, and prevent falls.
Higher bleeding rates seen in older adult women with STEMI suggest that bleeding prevention strategies must be emphasized in this population, especially in those undergoing PCI. This represents an important future area for quality improvement efforts.
Recognition is the first step towards closing these gaps in AMI care. While substantial efforts are being made to reduce sex differences in care across the age spectrum, some of the more geriatric-specific issues identified here must be considered as we meet these challenges going forward.
By: Michael Nanna, MD
Dr. Nanna is a Cardiovascular Disease Fellow at Duke University School of Medicine.
Frailty, a disorder of impaired recovery after illness, is closely linked to mortality, but is not accounted for by many large-scale risk adjustment metrics since rigorous measurement of frailty can be time-intensive. Thus, it is unclear if failure to account for frailty in risk adjustment methods results in undue penalties for hospitals taking care of large numbers of frail individuals.
In a retrospective cohort analysis of 785,127 Medicare Fee-for-Service beneficiaries, Kundi et al. used a claims-based frailty index – known as the Hospital Frailty Risk Score (HFRS) –to overcome the problem of time-intensive frailty measurement. The HFRS is a frailty index tied to clusters of resource utilization developed in a British population and subsequently externally validated in a Canadian population. The HFRS was created to further define patients at risk for poor outcomes by evaluating which administrative billing codes best identify individuals with prolonged hospital stay, increased rates of readmission, and increased rates of mortality. These billing codes were then tallied to categorize patients into 3 risk groups including low (<5), intermediate (5-15), and high (>15) risk. The HFRS has subsequently been associated with increased mortality after transcatheter aortic valve replacement (TAVR) within the United States.
In the current study, Kundi et al. found that including the HFRS in the risk adjustment model used to calculate risk-standardized 30-day readmission rates (RSRSs) for acute myocardial infarction, heart failure, and pneumonia hospitalizations improved prediction of 30-day readmission and short-term mortality compared to use of clinical comorbidities alone. Across all 3 conditions, addition of the HFRS resulted in a statistically significant (p < 0.001) improvement in prediction of 30-day readmission and short-term mortality after adjusting for age, sex, race, and other comorbidities. These results imply that hospitals caring for high numbers of frail individuals may be disproportionately penalized for the quality of care delivered if frailty is not considered in risk adjustment algorithms, including the one used by the Centers for Medicare and Medicaid Services (CMS).
Notably, frailty as defined by the HFRS only moderately correlates with two common definitions used by Fried and Rockwood. The HFRS defines frailty according to clusters of increased health resource utilization and adverse outcomes, so-called “utilization frailty,” and thus represents a distinct definition that may correlate only moderately with “syndromic frailty.” Nevertheless, as this and other papers suggest, this definition identifies a higher risk subpopulation that is relevant to both clinical risk prediction and high healthcare utilization. This classification of frailty is increasingly important as the Medicare population continues to age and hospitals seek to tailor their post-discharge care for these high utilizing individuals.
In summary, the recent publication by Kundi et al. highlights the importance of risk adjustment for “utilization frailty” when assessing risk of short-term readmission and mortality after hospitalizations for three common acute medical conditions. As detailed in the study, the HFRS could be used to identify and create care plans for patients that are high risk for readmission and mortality. Future research is needed to identify if hospitals that take care of higher numbers of frail patients are disproportionality penalized under the Hospital Readmissions Reduction Program (HRRP). In addition, the role of hospital-based interventions for high-risk frail patients to prevent adverse post-acute care outcomes warrants further inquiry.
By: Lila M Martin, MD, MPH; Jordan B Strom, MD, MSc, FACC, FASE
Hospices provide palliative and supportive services to people who are nearing the end of life. More people in the U.S. are using hospice than ever before—recent data indicate that half of those with Medicare insurance who died in 2017 used hospice. Hospices are also serving a more diverse population and reaching people with a range of diseases, including heart failure. While this is encouraging news, patients with heart failure face unique challenges in hospice. Because of difficulties in making accurate pro
gnosis estimates, many patients with heart failure are referred to hospice too early or late in the disease process. Also, heart failure causes sudden changes in physical functioning and symptoms that can be difficult to manage at home. These difficulties can make it more likely that patients with heart failure end up leaving hospice prior to death, an event that is also known as “live discharge.”
A study that we recently published in JACC: Heart Failure found that 30% of patients with heart failure experience a live discharge from hospice. We found that this occurs much more frequently in heart failure compared to other diseases like cancer and stroke. Live discharge can happen for several reasons, including unanticipated medical events that lead to hospitalization, decisions by patients and their families to pursue disease-directed treatments that are not allowed under hospice regulations (“elective revocation”), leaving the hospice’s service area, or having an extended prognosis beyond the six-month eligibility window.
Which heart failure patients are more likely to leave hospice before death–“live discharge”?
Data that we gathered from a large population of patients in New York City allowed us to explore factors that were linked with live discharge from hospice:
- Younger patients between the ages of 18 and 74 are more likely to leave hospice because of hospitalizations or elective revocations.
- Patients from underrepresented racial/ethnic backgrounds, including black and Hispanic patients, are more than twice as likely to leave hospice because of hospitalization.
- Higher functioning patients who are more mobile and less reliant on assistance, measured by scores of 50-70% on the Palliative Performance Scale, are more likely to experience live discharge.
————-Read more by clicking on the link above————–
We recently published a paper on predicting 30-day readmission for older adults with acute myocardial infarction (AMI) in Circulation: Cardiovascular Quality and Outcomes. Our purpose was to evaluate whether aging-related functional impairments in mobility, cognition, and sensory domains would help to predict whether AMI patients would be readmitted to the hospital within 30 days or discharged, which has been subject of increasing focus by payors and health systems over the past decade. We analyzed data from the SILVER-AMI study, which exclusively enrolled participants 75 aged years or older, and included a detailed assessment of functional impairments.
————-Read more by clicking on the link above————–
Perfect pairings: Peanut butter and jelly. Grilled cheese and tomato soup. Smartphones and geriatric patients?
While most people probably don’t picture their older adult relatives Facetiming their doctor on their iPhone or sporting a Fitbit to the gym, this could very well be the future of preventive medicine. According to a 2016 Pew Research Center poll, 42% of adults over age 65 owned smartphones, up from 11% in 2011. With this rise in mobile technology ownership, there is new opportunity for patient engagement and management beyond the traditional face-to-face encounter. Older adults, especially those with cardiovascular disease, seem well-positioned to gain considerable benefit from mobile health (mHealth) technology. Their propensity for multimorbid disease, mobility impairment, social isolation, and transportation issues means that older adults have both elevated clinical needs and substantial barriers to traditional care strategies. In order to better understand the relative utility of mHealth technologies in older adult patients, we conducted a narrative literature review recently published in Current Geriatrics Reports.
What did we find?
- There is a wealth of mHealth apps and wearable devices designed to aid in the monitoring of older adult patients with cardiovascular disease.
- Adoption of mHealth technology by older adults is impeded by well-documented barriers that are physical, cognitive, and motivational in nature.
- The physical and cognitive challenges can be partially alleviated with engineered solutions that make the mobile interface easier to use.
- However, motivational barriers require personalized coaching and social support, which are unlikely to be overcome by engineered solutions alone.
- Studies to date have shown mixed results when mHealth interventions are adopted. More research is needed to prove their usefulness in the home setting.
What does this mean?
In short, there are still barriers to mHealth becoming standard in the treatment of cardiovascular disease in older adults. That being said, several trials have demonstrated significant improvement in blood pressure monitoring, heart failure management, arrhythmia monitoring, medication adherence, and feelings of social isolation. While it is important to keep in mind that results have been mixed with regard to the efficacy of specific mHealth intervention strategies, it makes logical sense that using smartphones and other devices to gather more patient data points between office visits would facilitate more informed care. It is critical to ensure that these strategies 1) produce trustworthy and reliable information and 2) are cost-effective.
Where do we go from here?
Moving forward, it is essential that mHealth developers incorporate the specific engineering solutions to aging-related problems outlined both in our review article and elsewhere to facilitate use with older adults. We must also continue to investigate whether mHealth interventions can be an effective and appropriate supplement to existing care paradigms in the treatment of cardiovascular disease. Though it is still too early to be certain, we believe there is great potential in mHealth interventions for older adults, and we are excited to see the ways in which technology is incorporated into patient care.
By: Ryan Searcy
Ryan is a 2nd-year medical student at the University of North Carolina-Chapel Hill School of Medicine. Ryan was also a Medical Student Training in Aging Research (MSTAR) Program scholar at NYU School of Medicine, where he participated in aging-related research and geriatrics.
What is the CoMPAdRE program?
The CoMPAdRE program is an interprofessional, early career mentorship program for faculty who are interested in patient-centered aging research. The acronym CoMPAdRE stands for Columbia University Mentor Peer Aging Research. Compadre also means “friend or companion,” representing the purpose of this program—to build a network of peer relationships that can be sustained over the course of a career.
Many traditional mentoring programs are structured as dyadic relationships between a senior mentor and junior mentee. However, this traditional dyadic model can put undue pressure on both the mentor and mentee. Moreover, mentees may have trouble identifying senior mentors who are available and willing to invest the time needed to develop a productive dyadic relationship. This issue is particularly problematic for women and racial and ethnic minorities who traditionally have had less access to professional networks (additional information here) with potential senior mentors. There is a large body of research demonstrating the benefits of mentorship, such as access to career development opportunities; therefore, individuals who are excluded from mentorship opportunities are often disadvantaged with regard to career development. CoMPAdRE seeks to address shortcomings of traditional mentoring programs by offering a new model: a hybrid of a dyadic and peer mentorship model, known as facilitated peer mentorship. The program is led by a senior mentor, Mathew Maurer MD, but the focus is on building a strong, interprofessional peer network.
Why is this program interprofessional?
Over the past decade, the care of older adults has become much more clinically complex and fragmented. As patients live longer with multiple comorbid conditions, they are receiving care from a number of specialized providers, creating greater possibilities for fragmentation in care. Collaborative mentorship teams facilitate sharing of ideas and learning opportunities across disciplines. For example, when caring for older adults with heart failure, programs such as the Heart Failure with Preserved Ejection Fraction Program at Weill Cornell Medicine include physicians, nurses, and social workers. Both holistic patient care and thought leadership require an interprofessional team that bring together specific domain expertise. By bringing together a diverse cohort of health professionals from across the country, CoMPAdRE has facilitated a unique learning experience for sharing ideas, developing skills, and building relationships.
How does CoMPAdRE impact patients?
The value of mentorship goes back to the underlying importance of reducing clinician burnout and supporting sustainability. When healthcare providers feel connected through a common mission, they have more capacity to fully engage with the needs of their patients, and conduct high-impact research focused on improving patient outcomes. Clinicians and researchers thrive most when they feel their work is valued.
What will you take away from this program?
Mentorship and giving back to the community takes place at every career stage. CoMPAdRE has hosted many global leaders in aging including Drs. Luigi Ferrucci, Linda Fried, Stephanie Studenski, Terry Fulmer, Mary Tinetti, and Mark Supiano, among others. Each speaker not only shared their career highlights, but the accompanying personal stories that paralleled the highs and lows of their careers. As a group, we learned how to manage time, stay focused, and most of all, value and cultivate relationships. A major theme of discussion throughout the program was that, over the course of clinical training, skills in management, leadership, and administration are not taught, and yet are expected as part of the job. One of the benefits of this program is that it provides the mentees with a structured opportunity to learn more about these skills with direct application into our clinical practices and programs of research.
Despite being a program for “early career” faculty, we were all encouraged to not only seek out mentorship and support, but to also serve as mentor to others. A critical takeaway point from this program was the necessity of mentoring at all career levels; it is never too early or too late to support others through mentorship.
How can we find out more about the program?
If you are interested in finding out more information about this CoMPAdRE program, you can read more details about this program in the Journal of the American Geriatrics Society.
By: Ruth Masterson Creber, PhD, MSc, RN
Ruth Masterson Creber is an Assistant Professor of the Department of Healthcare Policy and Research at Weill Cornell Medicine.
Our recent Council review paper from the American College of Cardiology Geriatric Cardiology Section Leadership Council enumerated the potential role for a multi-domain approach to caring for older adults with heart failure. As shown in the proposed Domain Management approach to heart failure, domains including medical, mind and emotion, function, and social environment should be routinely considered when caring for older adults with heart failure.
While this Domain Management approach is applicable to any type of heart failure, it is especially relevant when caring for individuals with heart failure with preserved ejection fraction (HFpEF), a subtype that comprises 50% of heart failure cases across the United States. HFpEF may be described as a geriatric syndrome, as aging processes including biological changes to the cardiovascular system and age-related comorbid conditions have been implicated in its pathogenesis. Indeed, epidemiologic studies have shown that HFpEF disproportionately affects older adults. Consequently, management of patients with HFpEF should incorporate aspects of care needed to address the unique vulnerabilities of older adults. For example, patients with HFpEF almost universally experience multimorbidity (the condition of having multiple chronic conditions) and polypharmacy (high burden of medications); frequently experience cognitive and functional impairment; and often experience changes within their social environment relating to social support, their peer network, and/or financial state. The Domain Management approach provides a framework for clinicians to address each of these four domains, promoting a holistic approach to heart failure care.
What might the application of a Domain Management approach in clinical practice for the care of patients with HFpEF look like? Our recently-established Heart Failure with Preserved Ejection Fraction Program at Weill Cornell Medicine/New York Presbyterian Hospital could offer a model for incorporating the Domain Management approach. For the medical domain, we obtain a detailed history that focuses on both cardiac and non-cardiac conditions, and also perform a thorough review of medications (with physical pill bottles when possible) that include prescription medications, over-the-counter medications, and nutritional supplements. We pay special attention to the number of medications and regimen complexity, both of which can undermine medication adherence. For the mind and emotion domain, we routinely screen for cognitive impairment (via the Mini-Cog, which takes <2 minutes to administer) and for depressive symptoms using the PHQ-2/9 (2-4 minutes), both of which can negatively impact self-care. For the function domain, we screen for frailty and mobility limitations by conducting the short physical performance battery (approximately 5 minutes) which assesses core strength, balance, and gait speed. We also inquire about orthostatic symptoms and a history of falls. Our functional assessments have particularly important implications on prognosis as well as decision-making with regard to blood pressure targets. Lastly, for the social environment domain, we take a detailed social history that includes an assessment of their social network and sources of emotional and financial support. To address potential concerns related to this domain, our HFpEF Program has a dedicated Social Worker.
While formal assessment of each domain increases the duration of the office visit, we believe that the Domain Management approach facilitates a more nuanced approach to caring for older adults with HFpEF that is comprehensive and patient-centric. Information acquired for each domain can have a significant impact on discussions relating to the potential benefits and risks of various diagnostic and therapeutic interventions. Accordingly, we believe that the Domain Management approach is critically important to facilitate shared-decision making. Whether the Domain Management approach can improve outcomes is unclear; in the future, we hope to share our experience as it relates to outcomes. Until then, it would seem that any process that can help with decision-making in a complex condition like HFpEF would be worth the extra time and effort.
By: Parag Goyal, MD
Dr. Goyal is an Assistant Professor of Medicine in the Division of General Internal Medicine and the Division of Cardiology at Weill Cornell Medical Center, and is leading a new HFpEF program at New York Presbyterian/Weill Cornell Medical Center.
I wrote a piece on the importance of conversations with our older patients (and the inability of technology to replace these) on Kevin MD last week. I’m providing a link to the article here. In an era of rapid technological change, it’s important to remember that our older patients are unique, not only in their life experiences, but also in their impairments, care preferences, and social context. While technology will play a role, it’s essential not to lose sight of the importance of investing in the future geriatric workforce. In addition, developing novel clinical programs tailored towards older adults’ needs, given our changing demographics, is vital. There’s a lot of innovative work being done in this arena which we’ll be featuring (along with other content) in the coming year.
By: John Dodson, MD, MPH
Approximately 5.7 million U.S. adults have heart failure (HF), and 1 in 5 individuals over age 40 will develop HF in their lifetimes. HF is accompanied by many symptoms – including fatigue, shortness of breath, mood changes, pain, and anorexia. Among older adults with HF, these symptoms are compounded by mobility limitations, frailty, and other co-morbidities. Palliative Care is an optimal way to address symptoms while concurrently treating with disease-modifying interventions (Figure 1).
Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual…Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life.”
Palliative care can help HF patients in several ways. First, the palliative care team can work with a patient’s cardiologist in proactively treating symptoms as they develop over the course of the illness and during times of exacerbations. While the underlying cause of these symptoms is not completely understood, hypotheses suggest that physiological changes contribute to symptom burden (Figure 2).
One of the most common symptoms with heart failure is dyspnea, and a patient’s cardiologist and palliative care clinician may work together to treat dyspnea by using diuretics to optimize fluid status, teaching breathing techniques, and (in advanced disease) administering a low dose opioid such as morphine to alleviate shortness of breath. These treatments have the unified goal of improving a patient’s quality of life.
Second, palliative care assists with effective communication between patients and clinicians in the form of advanced care planning – including establishing a health care proxy, completing advanced directives, discussing goals of care, and having end of life conversations regarding when to stop certain interventions. Advanced care planning discussions help to ensure patients’ preferences for what is most important in their care are met.
Goodlin et al provide examples of language clinicians may use to eliciting these preferences, such as “What treatment we recommend depends on your medical condition, but also on what approach to care you prefer and what is important to you at this point in your life”. This statement allows a platform for patients to express their wishes and what quality of life means to them. Their clinician is then able to recommend treatments that align with their goals and preferences.
HF is a common disease with a dynamic trajectory due to periods of exacerbation and recovery. It is imperative that cardiologists and palliative care clinicians work together to provide disease-modifying interventions while concurrently treating symptoms and developing advanced care plans with patients.
For more information on Palliative Care in Heart Failure visit the following websites:
By: Megan E. Rau, MD, MPH
Dr. Rau is a practicing physician at NYU Langone Health who specializes in geriatrics and palliative care & hospice.
Frailty (a state of increased vulnerability to physiologic stressors) is common in older adults. Frailty can be measured in several ways, including by a simple test such as walking speed or more thorough criteria. The geriatrics community has long recognized that frailty predicts hospitalization, functional decline, and death. Cardiologists are increasingly recognizing the importance of frailty as well: for example, in predicting outcomes after cardiac surgery and myocardial infarction.
Building on this work, we recently published a paper in JACC: Cardiovascular Interventions that highlighted the role of frailty in predicting bleeding among cardiac patients with myocardial infarction in the ACTION registry. While the link may not seem intuitive, there are a number of reasons frailty may confer bleeding risk, including poor vascular integrity, altered hemostatic factors, and issues related to treatments (e.g. overdosing of anticoagulants).
There were several key findings from our work: first, frailty increased bleeding risk by 50%; second, this was only seen in patients undergoing cardiac catheterization; third, the use of strategies that may reduce bleeding (radial access, and proper dosing of anticoagulant medications) was relatively low. The findings in this large cohort largely confirmed what had been shown previously in smaller studies.
I think there are several actionable steps from this work. First, frailty matters – and we should start measuring it. Our study used a combination of variables abstracted from the medical record, which may have under-detected the true prevalence of frailty. Walking speed, an alternative measure of frailty, can be easily obtained in the hospital on most patients and is easily reproducible. Second, for frail patients, bleeding avoidance strategies are critical. For example, radial access was only used in only 1 in 4 frail patients in our study. Randomized trials in older adults have used higher rates of radial access and have found less bleeding. So this seems to be one relatively straightforward way to improve outcomes in our frail patients.
By: John Dodson, MD, MPH
Last week, I had the privilege of attending the Geronotological Society of America (GSA) 2018 Annual Scientific Meeting that was held in Boston, MA this year with the theme centralized around “The Purpose of Longer Lives.” GSA is one of the oldest and largest interdisciplinary organizations that is well-attended nationally by scientists, clinicians, and students who all have one thing in common: a passion for gerontology research.
Aside from connecting with many respectable researchers in the field, I also had the opportunity to present findings from our qualitative research focusing on decisional needs among older adults with cardiovascular disease. Specifically, our study sought to investigate the perspectives of older adults on coronary interventional procedures after their hospitalization for acute myocardial infarction (otherwise known as AMI, or heart attack). In recent decades, older adults have been undergoing more coronary revascularization procedures for AMI (stent placements and coronary artery bypass surgery (CABG)); consequently, procedure-related risks are more common. Moreover, time-sensitive settings during AMI at times do not allow for easy shared decision-making (SDM) discussions with their clinicians to detail these risks. Our study therefore was interested in probing further into AMI patients’ decision-making process – and to identify what factors, exactly, that led them to decide on whether or not to undergo a coronary revascularization procedure.
Based on our preliminary research from 15 patients who had been hospitalized with AMI and discharged home, the main themes that emerged were as follows:
- Procedural risks are perceived to be minimal when compared to perceived benefits.
Perceived procedural risks – which were generally described to be stroke, bleeding, and death – were viewed minimally when compared to the benefits. When asked to list the perceived benefits, patients mentioned “living a healthy life,” “no pains,” and “prevention of future heart attacks.”
- Some respondents reported that the alternative to a procedure was death.
“I would not have come to the hospital if I wanted to commit suicide,” stated one respondent. While this may be seemingly viewed as a more extreme perception of the alternative to the procedure, this theme was seen across several respondents. For example, another said, “That [turning down the procedure] didn’t enter my mind at all. In fact, I would’ve been dead at this point.” Most participants viewed that they “had no choice,” stating that they would not have been alive without the interventional procedure, and as a result, viewed the procedure was an absolute necessity.
- Participants place a high level of trust in their cardiologists when making decisions.
A majority of respondents revealed that faith in the physician was also a major factor contributing to their decision-making process—regardless of how long they have known their cardiologist. While one participant was loyal to their outpatient cardiologist of 28 years, others put an equal amount of trust in the interventional cardiologist whom they met on the same day of the procedure. One respondent, who was unconscious during her episode, stated: “I wasn’t thinking straight, but I had total belief that the doctors were going to take care of me.”
- Receiving procedural information, before or after the procedure, could aid in a better overall satisfaction of the experience.
All participants expressed that it was very important for them to understand their heart disease and associated procedures – even if it is after the procedure was completed. This was especially predominant among participants who had an ST-elevation MI (STEMI) who underwent their procedure rapidly. Some suggestions on how this could be achieved include providing a copy of the angiogram results, providing pamphlets and brochures, and sending medical personnel to explain the procedure more in-depth immediately pre-procedure, or during early recovery.
- All participants highly value what is perceived to be SDM.
All of our respondents, regardless of whether or not they have received a procedure, expressed a desire to have a discussion with their clinicians regarding their treatment options and the risks and benefits of a procedure.
Based on our findings, SDM has the potential to better overall patient knowledge and satisfaction with care. SDM is probably most applicable in the setting of non-ST segment AMI (NSTEMI) where there is time for more informed discussions. Notably, NSTEMI is the most common AMI presentation among older adults. We believe our work supports the future utilization of SDM in clinical practice, and perhaps, a future tool designed to better expedite the SDM process in the inpatient setting.
By: Jenny Summapund, MA
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).
Naik et al., “Development of a Clinically-Feasible Process for Identifying Patient Health Priorities.”
By: John Dodson, MD, MPH
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.