Prevalent Statin Use in Long-Stay Nursing Home Residents with Life-Limiting Illness

Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life

INTRODUCTION

Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing.

OBJECTIVE

This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life.

METHODS

We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions.

RESULTS

Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing.

CONCLUSIONS

Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.

Statin Use and All-Cause Mortality in Nursing Home Residents With and Without Dementia: A Retrospective Cohort Study Using Claims Data

BACKGROUND AND OBJECTIVES

Little is known about the benefits of statin therapy in older adults with dementia. We aimed to evaluate the role of statin use for all-cause mortality in nursing home residents with and without dementia.

METHODS

This retrospective cohort study used claims data collected between January 2015 and December 2019 from a German health and long-term care insurance provider. Propensity score-based Cox proportional hazards models were used to evaluate the association of statin use with all-cause mortality and adjusted for potential confounders in nursing home residents. Subgroup analyses were performed based on the presence or absence of atherosclerotic cardiovascular disease (ASCVD), statin intensity (low, moderate, high), dementia type, age, sex, and level of care required.

RESULTS

A total of 282,693 participants were included in the study, of which 96,162 were matched. In total, 68.9% were women, and the mean age was 82.91 years (SD ±7.97). The average observation period was 2.25 years (SD ±1.35), and 54,269 deaths were recorded. Statin use in individuals with dementia resulted in lower all-cause mortality (hazard ratio [HR] 0.80, 95% CI 0.78-0.82, p < 0.001) compared with statin nonusers. Similarly, in individuals without dementia, statin use was associated with lower all-cause mortality (HR 0.73, 95% CI 0.71-0.76, p < 0.001) compared with statin nonusers. Similar findings were observed in subanalyses excluding participants with a history of ASCVD and across subgroups stratified by age, sex, care level required, and dementia type. Statin benefits were consistent among individuals with and without dementia.

DISCUSSION

Statin benefits were consistent among individuals with and without dementia. Statin therapy may be continued in nursing home residents with dementia to mitigate the risk of all-cause mortality.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that nursing home patients receiving statins have a lower mortality rate, whether they have a dementia diagnosis or not.

Health profiles of older nursing home residents by suicidal ideation: A latent class analysis

OBJECTIVES

Identify the health profiles of older nursing home residents with and without at-admission self-reported suicidal ideation (SI) and examine the association between the identified profiles and self-reported SI at 90 days.

METHODS

Using the Minimum Data Set 3.0 and the ninth Patient Health Questionnaire-9 (PHQ-9) item, we identified 15,277 older residents with and 562,184 without self-reported SI at nursing home admission. Latent class analysis, using frailty, cognitive impairment, palliative care index, pain, and remaining PHQ-9 items as indicators, identified health profiles by at-admission SI and the BCH method estimated their association with SI at 90 days.

RESULTS

Profiles identified for residents without at-admission SI were: (1) frail and depressedNoSI (prevalence: 33.9%); (2) frail and severe cognitive impairmentNoSI (38.1%); (3) pre-frailNoSI (28.0%). Residents in the frail and depressedNoSI group had greater odds [adjusted OR: 2.80; 95% Confidence Interval: 2.60-3.00] while those in the frail and severe cognitive impairmentNoSI group had lower odds [aOR: 0.79; 95% CI: 0.71-0.86] of 90-day SI than those in the pre-frailNoSI group. Profiles identified for residents with at-admission SI were: (1) frail and all depressive symptomsSI (22.8%); (2) frail and some depressive symptomsSI (32.2%); (3) frail and severe cognitive impairmentSI (22.9%); (4) pre-frailSI (22.0%). Compared to those in the pre-frailSI group, residents in the frail and all depressive symptomsSI group had greater odds of continuing reporting SI at 90 days [aOR: 1.22; 95% CI:1.09-1.35].

CONCLUSIONS

Findings indicated unique health profiles of nursing home residents at higher risk of new onset of or continued SI.

Statin Intake and All-Cause Mortality among Older Nursing Home Residents

BACKGROUND

Statins are progressively accepted as being associated with reduced mortality. However, few real-world statin studies have been conducted on statin use in older people and especially the most frail, that is, the nursing home residents.

OBJECTIVE

The aim of this study was to evaluate the impact of statin intake in nursing home residents on all-cause mortality.

METHOD

This is a cross-sectional study of 1,094 older people residing in 6 nursing homes in Flanders (Belgium) between March 1, 2020 and May 30, 2020. We considered all residents who were taking statins for at least 5 days as statin users. All-cause mortality during the 3 months of data collection was the primary outcome. Propensity score overlap-weighted logistic regression models were applied with age, sex, functional status, diabetes, and cardiac failure/ischemia as potential confounders.

RESULTS

185 out of 1,094 residents were on statin therapy (17%). The statin intake was associated with decreased all-cause mortality: 4% absolute risk reduction; adjusted odds ratio 0.50; CI 0.31-0.81, p = 0.005.

CONCLUSIONS

The statin intake was associated with decreased all-cause mortality in older people residing in nursing homes. More in-depth studies investigating the potential geroprotector effect of statins in this population are needed.

Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness

BACKGROUND

Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits.

OBJECTIVE

To describe regional variation in statin use among residents with life-limiting illness.

RESEARCH DESIGN

Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files.

SETTING

Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States.

SUBJECTS

Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170).

MEASURES

Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65-75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals.

RESULTS

Statin use was prevalent (age 65-75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65-75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization.

CONCLUSIONS

Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.

National Trends in Statin Use among the United States Nursing Home Population (2011-2016)

BACKGROUND

Little is known about trends in statin use in United States (US) nursing homes.

OBJECTIVES

The aim of this study was to describe national trends in statin use in nursing homes and evaluate the impact of the introduction of generic statins, safety warnings, and guideline recommendations on statin use.

METHODS

This study employed a repeated cross-sectional prevalence design to evaluate monthly statin use in long-stay US nursing home residents enrolled in Medicare fee-for-service using the Minimum Data Set 3.0 and Medicare Part D claims between April 2011 and December 2016. Stratified by age (65-75 years, ≥ 76 years), analyses estimated trends and level changes with 95% confidence intervals (CI) following statin-related events (the availability of generic statins, American Heart Association/American College of Cardiology guideline updates, and US FDA safety warnings) through segmented regression models corrected for autocorrelation.

RESULTS

Statin use increased from April 2011 to December 2016 (65-75 years: 38.6-43.3%; ≥ 76 years: 26.5% to 30.0%), as did high-intensity statin use (65-75 years: 4.8-9.5%; ≥ 76 years: 2.3-4.5%). The introduction of generic statins yielded little impact on the prevalence of statins in nursing home residents. Positive trend changes in high-intensity statin use occurred following national guideline updates in December 2011 (65-75 years: β = 0.16, 95% CI 0.09-0.22; ≥ 76 years: β = 0.09, 95% CI 0.06-0.12) and November 2013 (65-75 years: β = 0.11, 95% CI 0.09-0.13; ≥ 76 years: β = 0.04, 95% CI 0.03-0.05). There were negative trend changes for any statin use concurrent with FDA statin safety warnings in March 2012 among both age groups (65-75 years: β trend change = - 0.06, 95% CI - 0.10 to - 0.02; ≥ 76 years: β trend change = - 0.05, 95% CI - 0.08 to - 0.01). The publication of the results of a statin deprescribing trial yielded a decrease in any statin use among the ≥ 76 years age group (β level change = - 0.25, 95% CI - 0.48 to - 0.09; β trend change = - 0.03, 95% CI - 0.04 to - 0.01), with both age groups observing a positive trend change with high-intensity statins (65-75 years: β = 0.11, 95% CI 0.02-0.21; ≥ 76 years: β = 0.05, 95% CI 0.01-0.09).

CONCLUSION

Overall, statin use in US nursing homes increased from 2011 to 2016. Guidelines and statin-related events appeared to impact use in the nursing home setting. As such, statin guidelines and messaging should provide special consideration for nursing home populations, who may have more risk than benefit from statin pharmacotherapy.

Statin Discontinuation and Life-Limiting Illness in Non-Skilled Stay Nursing Homes at Admission

OBJECTIVES

To estimate 30-day statin discontinuation among newly admitted nursing home residents overall and within categories of life-limiting illness.

DESIGN

Retrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files.

SETTING

U.S. Medicare- and Medicaid-certified nursing home facilities (n = 13,092).

PARTICIPANTS

Medicare fee-for-service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non-skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247).

MEASUREMENTS

Residents were categorized using evidence-based criteria to identify progressive, terminal conditions or limited prognoses (<6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission.

RESULTS

Overall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life-limiting illness classification (no life-limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end-of-life: 45.0%). Relative to those with no life-limiting illness, risk of 30-day statin discontinuation increased with life-limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10-1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43-1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42-1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life-limiting illness status.

CONCLUSION

Statin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.

Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life

BACKGROUND/OBJECTIVES

Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention.

DESIGN

Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims.

SETTING

VA NHs, known as community living centers (CLCs).

PARTICIPANTS

Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110).

MEASUREMENTS

Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission.

RESULTS

Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation.

CONCLUSION

Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.