Identifying the Gaps: Sex Differences in the Care of Older Adults Presenting with Acute MI

Michael Nanna MDSex 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. 

Utilization Frailty: a New Approach

 

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

 

 

 

Tailored risk for older adults: SILVER-AMI

dodson%20headshotWe 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 of discharge, 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 aged ≥75 years, and included a detailed assessment of functional impairments.

What we found:

  • Among 3006 study participants with AMI (mean age 81.5 years), 547 (18.2%) were readmitted within 30 days.
  • Readmitted participants were older, with more comorbidities, and had a higher prevalence of functional impairments including disability in activities of daily living (17.0% vs. 13.0%), impaired functional mobility (72.5% vs. 53.6%) and weak grip strength (64.4% versus 59.2%).
  • After statistical modeling, our final risk model included 8 variables: functional mobility, ejection fraction, chronic obstructive pulmonary disease, arrhythmia, acute kidney injury, first diastolic blood pressure, P2Y12 inhibitor use, and general health status. While functional mobility was the only aging-related functional impairment retained in this model, it was also the strongest individual predictor.

Our risk model was well calibrated across categories of risk but had only modest discrimination – meaning there were other factors contributing to readmission risk (for example, related to the care environment or health system), that were not captured in SILVER-AMI.

Our hope is that our score can be used in a practical setting – for example, identifying patients for more intensive post-discharge care. Accordingly, our calculator is freely available at silverscore.org, or in the App Store here.

 

By: John Dodson, MD, MPH

 

“I Had No Choice”: Perspectives from Heart Attack Patients on Coronary Interventional Procedures

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Photo taken at Boston Public Garden

Last week, I had the privilege of attending the Gerontological 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:

  1. 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.”

  1. 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.

  1. 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.”

  1. 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.

  1. 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

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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.