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 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.
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:
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.
Several 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:
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.
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.
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.
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.
Apersonalized (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.
Treadmills, elliptical machines, and tennis shoes; objects commonly associated with leisure time and fitness training are abundant on the 16th floor of the NYU Ambulatory Care Center, home to the NYU Cardiac Rehabilitation Program. Cardiac rehabilitation (CR) programs involve regimented, structured physical activity and are typically employed over the course of many weeks; at NYU, the standard schedule involves supervised activity three times per week for three months.
Evidence suggests that participation in CR programs after hospitalization for a variety of cardiac conditions and procedures (including stable ischemic heart disease, heart failure, and following coronary revascularization) imparts real benefits including decreased cardiovascular-related mortality, reduced hospital admissions, and improvement in health-related quality of life. ACC/AHA guidelines accordingly assign a Class I recommendation for the prescription of CR programs to patients after hospitalization for acute coronary syndrome, post-revascularization, or heart failure.
Despite these recommendations, CR programs are underutilized. Studies (here and here) have noted that many patients who could benefit from participation in a CR program are not referred upon discharge, and under-referral is even more pronounced in older patients. Given that adults over the age of 65 have the highest rates of mortality related to acute myocardial infarction and heart failure, lack of referral for these patients may represent a glaring missed opportunity for significant impact.
Notably, in a recent observational study by Flint et. al. of patients aged ≥65 with acute myocardial infarction, those with slow gait speed – a marker of frailty – were less frequently referred to CR programs. While reasons for this phenomenon are likely multifactorial (e.g. transportation, lack of available facilities, physical limitations), an important and addressable factor is referral bias; clinicians may feel that a patient who is “too frail” may be unlikely to benefit from a program that includes frequent structured exercise. Notably, in the study by Flint et al., patients with slow gait speed who participated in a CR program garnered similar benefits in outcomes (mortality, maintenance of activities of daily living) when compared their less frail counterparts. These data (which build on previous observations) suggest that even older adults who are considered frail or have significant medical comorbidities benefit from standardized referral to CR.
Initial referral is just one of many potential barriers to participation in CR programs: economic and social factors contribute to reduced rates of participation and adherence. Time commitment, including distance from home to a CR program, has also been mentioned as a barrier to utilization. In this context, mobile health (mHealth) companies are rapidly moving to develop home-based CR programs that leverage existing technologies (smartphones, tablet devices, wearable monitors) with the promise that they can serve as either a substitute or adjunctive therapy to traditional ambulatory CR programs. If successful, they may fill a significant gap in our current care paradigms for older adults by reducing a number of barriers to participation in CR programs; but rigorous trials will be ultimately required to evaluate their efficacy.