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Levine DA, Whitney RT, Galecki AT, Fagerlin A, Wallner LP, Shore S, Langa KM, Nallamothu BK, Morgenstern LB, Giordani B, Reale BK, Blair EM, Sharma A, Kabeto MU, Plassman BL, Zahuranec DB. Patient Cognitive Status and Physician Recommendations for Cardiovascular Disease Treatment: Results of Two Nationwide, Randomized Survey Studies. J Gen Intern Med 2023; 38:3134-3143. [PMID: 37620721 PMCID: PMC10651817 DOI: 10.1007/s11606-023-08295-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 06/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Clinical guidelines recommend that older patients (65+) with mild cognitive impairment (MCI) and early-stage dementia receive similar guideline-concordant care after cardiovascular disease (CVD) events as those with normal cognition (NC). However, older patients with MCI and dementia receive less care for CVD and other conditions than those with NC. Whether physician recommendations for guideline-concordant treatments after two common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke (stroke), differ between older patients with NC, MCI, and early-stage dementia is unknown. OBJECTIVE To test the influence of patient cognitive status (NC, MCI, early-stage dementia) on physicians' recommendations for guideline-concordant treatments for AMI and stroke. DESIGN We conducted two parallel, randomized survey studies for AMI and stroke in the US using clinical vignettes where the hypothetical patient's cognitive status was randomized between physicians. PARTICIPANTS The study included cardiologists, neurologists, and generalists who care for most patients hospitalized for AMI and stroke. MAIN MEASURES The primary outcome was a composite quality score representing the number of five guideline-concordant treatments physicians recommended for a hypothetical patient after AMI or stroke. KEY RESULTS 1,031 physicians completed the study (58.5% response rate). Of 1,031 respondents, 980 physicians had complete information. After adjusting for physician factors, physicians recommended similar treatments after AMI and stroke in hypothetical patients with pre-existing MCI (adjusted ratio of expected composite quality score, 0.98 [95% CI, 0.94, 1.02]; P = 0.36) as hypothetical patients with NC. Physicians recommended fewer treatments to hypothetical patients with pre-existing early-stage dementia than to hypothetical patients with NC (adjusted ratio of expected composite quality score, 0.90 [0.86, 0.94]; P < 0.001). CONCLUSION In these randomized survey studies, physicians recommended fewer guideline-concordant AMI and stroke treatments to hypothetical patients with early-stage dementia than those with NC. We did not find evidence that physicians recommend fewer treatments to hypothetical patients with MCI than those with NC.
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Affiliation(s)
- Deborah A Levine
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA.
- Department of Neurology and Stroke Program, U-M, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, USA.
- Division of General Medicine, U-M, Ann Arbor, MI, USA.
| | - Rachael T Whitney
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
| | - Andrzej T Galecki
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
- Department of Biostatistics, U-M, Ann Arbor, MI, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, and Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center for Innovation, Salt Lake City, UT, USA
| | - Lauren P Wallner
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, USA
- Department of Epidemiology, U-M, Ann Arbor, MI, USA
| | - Supriya Shore
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
| | - Kenneth M Langa
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Social Research, U-M, Ann Arbor, MI, USA
| | - Brahmajee K Nallamothu
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Lewis B Morgenstern
- Department of Neurology and Stroke Program, U-M, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, USA
- Department of Epidemiology, U-M, Ann Arbor, MI, USA
| | - Bruno Giordani
- Department of Psychiatry, U-M, Ann Arbor, MI, USA
- Michigan Alzheimer's Disease Center, U-M, Ann Arbor, MI, USA
| | - Bailey K Reale
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
- Lake Erie College of Osteopathic Medicine, Erie, PA, USA
| | - Emilie M Blair
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
| | - Anupriya Sharma
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
| | - Mohammed U Kabeto
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA
| | - Brenda L Plassman
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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Blair EM, Reale BK, Zahuranec DB, Forman J, Langa KM, Giordani BJ, Plassman BL, Welsh-Bohmer KA, Wang J, Kollman CD, Levine DA. Influence of mild cognitive impairment on patient and care partner decision-making for acute ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107068. [PMID: 37004301 PMCID: PMC10499500 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 04/03/2023] Open
Abstract
GOALS Evidence suggests that patients with mild cognitive impairment (MCI) receive fewer treatments for acute ischemic stroke and other cardiovascular diseases than patients with normal cognition. Little is known about how patient and care partner preferences for ischemic stroke treatment differ between the patient population with MCI and the population with normal cognition. This study aimed to understand how patient MCI diagnosis influences patient and care partner decision-making for acute ischemic stroke treatments. METHODS Multi-center qualitative study using in-person semi-structured interviews with 20 MCI and normal cognition patient-care partner dyads using a standard guide. The present study reports results on patient and care partner preferences for a clinical vignette patient to receive three non-invasive treatments (intravenous tissue plasminogen activator, inpatient rehabilitation, and secondary preventive medications) and two invasive treatments (feeding tube and carotid endarterectomy) after acute ischemic stroke. We used qualitative content analysis to identify themes. FINDINGS We identified three major themes: (1) Patients with MCI desired non-invasive treatments after stroke, similar to patients with normal cognition and for similar reasons; (2) Patients with MCI expressed different preferences than patients with normal cognition for two invasive treatments after stroke: carotid endarterectomy and feeding tube placement; and (3) Patients with MCI expressed more skepticism of the stroke treatment options and less decisiveness in decision-making than patients with normal cognition. CONCLUSIONS These results suggest that patient MCI diagnosis may contribute to differences in patient and care partner preferences for invasive treatments after stroke, but not for non-invasive treatments.
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Affiliation(s)
- Emilie M Blair
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA
| | - Bailey K Reale
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA; Lake Erie College of Osteopathic Medicine at Seton Hill, LECOM, Greensburg, PA, USA
| | | | - Jane Forman
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Institute for Social Research, U-M, Ann Arbor, MI, USA
| | - Kenneth M Langa
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Institute for Social Research, U-M, Ann Arbor, MI, USA
| | - Bruno J Giordani
- Department of Psychiatry and Michigan Alzheimer's Disease Center, U-M, Ann Arbor, MI, USA
| | - Brenda L Plassman
- Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA
| | - Kathleen A Welsh-Bohmer
- Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA
| | - Jing Wang
- Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA
| | | | - Deborah A Levine
- Department of Internal Medicine and Cognitive Health Services Research Program, U-M Medical School, Ann Arbor, MI, USA; Department of Neurology and Stroke Program, U-M, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
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Levine DA, Galecki AT, Morgenstern LB, Zahuranec DB, Langa KM, Kabeto MU, Okullo D, Nallamothu BK, Giordani B, Reale BK, Campbell M, Lisabeth LD. Preexisting Mild Cognitive Impairment, Dementia, and Receipt of Treatments for Acute Ischemic Stroke. Stroke 2021; 52:2134-2142. [PMID: 33902296 DOI: 10.1161/strokeaha.120.032258] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Differences in acute ischemic stroke (AIS) treatment by cognitive status are unclear, but some studies have found patients with preexisting dementia get less treatment. We compared AIS care by preexisting cognitive status. METHODS Cross-sectional analysis of prospectively obtained data on 836 adults ≥45 with AIS from the population-based Brain Attack Surveillance in Corpus Christi project from 2008 to 2013. We compared receipt of a composite quality measure representing the percentage of 7 treatments/procedures received (ordinal scale; values, <0.75, 0.75-0.99, and 1.0), a binary defect-free quality score, and individual treatments after AIS between patients with preexisting dementia (Informant Questionnaire on Cognitive Decline in the Elderly score ≥3.44), mild cognitive impairment (MCI, score 3.1-3.43), and normal cognition (score ≤3). RESULTS Among patients with AIS, 42% had normal cognition (47% women; median age [interquartile range], 65 [56-76]), 32% had MCI (54% women; median age, 70 [60-78]), 26% had dementia (56% women; median age, 78 [64-85]). After AIS, 44% of patients with preexisting dementia and 55% of patients with preexisting MCI or normal cognition received defect-free care. Compared with cognitively normal patients, patients with preexisting MCI had similar cumulative odds (unadjusted cumulative odds ratio =0.99, P=0.92), and patients with preexisting dementia had 36% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio [OR]=0.64, P=0.005). However, the dementia-quality association became nonsignificant after adjusting for patient factors, namely sex, comorbidity, and body mass index (adjusted cumulative OR [acOR]=0.79, P=0.19). Independent of patient factors, preexisting MCI was negatively associated with receipt of IV tPA (intravenous tissue-type plasminogen activator; acOR=0.36, P=0.04), rehabilitation assessment (acOR=0.28, P=0.016), and echocardiogram (acOR=0.48, P<0.001). Preexisting dementia was negatively associated with receipt of antithrombotic by day 2 (acOR=0.39, P=0.04) and echocardiogram (acOR=0.42, P<0.001). CONCLUSIONS Patients with preexisting MCI and dementia, compared with cognitively normal patients, may receive less frequently some treatments and procedures, but not the composite quality measure, after AIS.
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Affiliation(s)
- Deborah A Levine
- Department of Internal Medicine and Cognitive Health Services Research Program (D.A.L., A.T.G., K.M.L., M.U.K., D.O., B.K.N., B.K.R.), University of Michigan, Ann Arbor.,Department of Neurology and Stroke Program (D.A.L., L.B.M., D.B.Z., L.D.L.), University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation (D.A.L., L.B.M., K.M.L., B.K.N.), University of Michigan, Ann Arbor
| | - Andrzej T Galecki
- Department of Internal Medicine and Cognitive Health Services Research Program (D.A.L., A.T.G., K.M.L., M.U.K., D.O., B.K.N., B.K.R.), University of Michigan, Ann Arbor.,Department of Biostatistics (A.T.G.), University of Michigan, Ann Arbor
| | - Lewis B Morgenstern
- Department of Neurology and Stroke Program (D.A.L., L.B.M., D.B.Z., L.D.L.), University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation (D.A.L., L.B.M., K.M.L., B.K.N.), University of Michigan, Ann Arbor.,Department of Epidemiology (L.B.M., L.D.L.), University of Michigan, Ann Arbor
| | - Darin B Zahuranec
- Department of Neurology and Stroke Program (D.A.L., L.B.M., D.B.Z., L.D.L.), University of Michigan, Ann Arbor
| | - Kenneth M Langa
- Department of Internal Medicine and Cognitive Health Services Research Program (D.A.L., A.T.G., K.M.L., M.U.K., D.O., B.K.N., B.K.R.), University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation (D.A.L., L.B.M., K.M.L., B.K.N.), University of Michigan, Ann Arbor.,VA Ann Arbor Healthcare System, MI (K.M.L., B.K.N.)
| | - Mohammed U Kabeto
- Department of Internal Medicine and Cognitive Health Services Research Program (D.A.L., A.T.G., K.M.L., M.U.K., D.O., B.K.N., B.K.R.), University of Michigan, Ann Arbor
| | - Dolorence Okullo
- Department of Internal Medicine and Cognitive Health Services Research Program (D.A.L., A.T.G., K.M.L., M.U.K., D.O., B.K.N., B.K.R.), University of Michigan, Ann Arbor
| | - Brahmajee K Nallamothu
- Department of Internal Medicine and Cognitive Health Services Research Program (D.A.L., A.T.G., K.M.L., M.U.K., D.O., B.K.N., B.K.R.), University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation (D.A.L., L.B.M., K.M.L., B.K.N.), University of Michigan, Ann Arbor.,VA Ann Arbor Healthcare System, MI (K.M.L., B.K.N.)
| | - Bruno Giordani
- Department of Psychiatry and Michigan Alzheimer's Disease Center (B.G.), University of Michigan, Ann Arbor
| | - Bailey K Reale
- Department of Internal Medicine and Cognitive Health Services Research Program (D.A.L., A.T.G., K.M.L., M.U.K., D.O., B.K.N., B.K.R.), University of Michigan, Ann Arbor
| | - Morgan Campbell
- Neuroscience Institute and Stroke Program Medical Director, Christus Spohn Shoreline, Corpus Christi, TX (M.C.)
| | - Lynda D Lisabeth
- Department of Neurology and Stroke Program (D.A.L., L.B.M., D.B.Z., L.D.L.), University of Michigan, Ann Arbor.,Department of Epidemiology (L.B.M., L.D.L.), University of Michigan, Ann Arbor
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