Impact of multimorbidity on clinical outcomes in older adults with cardiovascular disease

Objective: To synthesize the current literature on the magnitude and impact of multiple chronic conditions on clinical outcomes, including total in-hospital and post discharge mortality and hospitalizations, in older patients with cardiovascular disease (CVD). Methods: A systematic review was conducted. Four electronic databases and article bibliographies were searched for publications from 2005 to 2015 which assessed the impact of multimorbidity on clinical outcomes in the elderly with CVD. Identified studies were screened using pre-defined criteria for eligibility. Results: Fifteen studies met our inclusion criteria. Multimorbidity was assessed by simple counting of morbidities and by the Charlson and Elixhauser indices. Case-fatality rates ranged from between 13% and 21% for patients with a myocardial infarction. Long-term mortality ranged from 28% to 73% among patients with heart failure, and 24% of patients with heart failure and presenting multimorbidities had at least one readmission during a follow-up period of 17 months. Most of the studies reported a significant association between number of multimorbidities or particular morbidities and the risk of dying, the most frequent morbidities examined were diabetes, chronic kidney disease, anemia, chronic pulmonary disease and dementia/cognitive impairment Conclusions: There are limited data on the magnitude and impact of multimorbidities on clinical outcomes, and even less data on patient centered outcomes among elderly patients with CVD. There are also inconsistencies in the manner by which multimorbidities are assessed; very few studies have approached the “real” complexity of patients with CVD and multimorbidities and how best to manage these high risk patients

Age and sex differences in long-term outcomes following implantable cardioverter-defibrillator placement in contemporary clinical practice: findings from the Cardiovascular Research Network

BACKGROUND: Patient sex and age may influence rates of death after receiving an implantable cardioverter-defibrillator for primary prevention. Differences in outcomes other than mortality and whether these differences vary by heart failure symptoms, etiology, and left ventricular ejection fraction are not well characterized. METHODS AND RESULTS: We studied 2954 patients with left ventricular ejection fraction \u3c /=0.35 undergoing first-time implantable cardioverter-defibrillator for primary prevention within the Cardiovascular Research Network; 769 patients (26%) were women, and 2827 (62%) were aged \u3e 65 years. In a median follow-up of 2.4 years, outcome rates per 1000 patient-years were 109 for death, 438 for hospitalization, and 111 for heart failure hospitalizations. Procedure-related complications occurred in 8.36%. In multivariable models, women had significantly lower risks of death (hazard ratio 0.67, 95% CI 0.56 to 0.80) and heart failure hospitalization (hazard ratio 0.82, 95% CI 0.68 to 0.98) and higher risks for complications (hazard ratio 1.38, 95% CI 1.01 to 1.90) than men; patients aged \u3e 65 years had higher risks of death (hazard ratio 1.55, 95% CI 1.30 to 1.86) and heart failure hospitalization (hazard ratio 1.25, 95% CI 1.05 to 1.49) than younger patients. Age and sex differences were generally consistent in strata according to symptoms, etiology, and severity of left ventricular systolic dysfunction, except the higher risk of complications in women, which differed by New York Heart Association classification (P=0.03 for sex-New York Heart Association interaction), and the risk of heart failure hospitalization in older patients, which differed by etiology of heart failure (P=0.05 for age-etiology interaction). CONCLUSIONS: The burden of adverse outcomes after receipt of an implantable cardioverter-defibrillator for primary prevention is substantial and varies according to patient age and sex. These differences in outcome generally do not vary according to baseline heart failure characteristics

Reperfusion therapy for acute myocardial infarction: observations from the National Registry of Myocardial Infarction 2

The National Registry of Myocardial Infarction 2 (NRMI-2) provides a unique opportunity to evaluate the practice patterns among participating cardiology and emergency medicine departments involved in the care of patients with acute myocardial infarction. The data from NRMI-2 suggest that almost 1/3 of all non-transfer-in and non-transfer-out patients are eligible for reperfusion therapy. Furthermore, of those patients who are clearly eligible for reperfusion therapy, 24% are not given this proven therapy. Specifically, women, the elderly, patients without chest pain on presentation, and those patients at highest risk for in-hospital mortality were least likely to be treated with reperfusion therapy. The reason for underuse of reperfusion therapy may in part reflect a concern for adverse bleeding events associated with the use of thrombolytic therapy. The data from NRMI-2 also suggest that patients with contraindications to thrombolysis may be very appropriate for primary angioplasty. Realizing the full potential benefits of reperfusion therapy in terms of reduced cardiovascular morbidity and mortality will require that clinical practice patterns be aligned more closely with the recommended national guidelines, which are based on extensive clinical trial data that show the benefit of reperfusion therapy in a wide range of patients with acute myocardial infarction. By using observational databases, such as the NRMI-2, which describe how clinical care is administered in nonclinical trial settings, we can continually monitor our progress and initiate changes to ensure that patients are given access to the many therapies that have been shown to improve their quality of life and survival

Using Home Visits to Understand Medication Errors in Children

Summary: Current research methods are not well designed to detect medication errors that occur at home. We developed home visit methods to investigate home medication errors in children with chronic conditions. These methods include observation of parent administration of medication to the child by a trained nurse observer who takes detailed ethnographic notes; review of all prescription and over-the-counter medications for dispensing errors, pill counts, and medication reconciliation; and parent interviews to identify barriers to effective home use of medications, prior home medication errors that parents are aware of, and suggestions for systemic improvements. Details about each possible error detected are recorded using a structured data collection form (allergies, medication list, dispensing errors, administration errors). We conducted several pilot home visits and found that this approach has the potential to help understand home medication errors in order to develop interventions to improve the safety of medication self-management

Factors Associated With Ordering Laboratory Monitoring Of High-Risk Medications

Background Knowledge about factors associated with provider ordering of appropriate testing is limited. Objective To determine physician factors correlated with ordering of recommended laboratory monitoring tests for high-risk medications, accounting for patient characteristics. Methods Analysis of the administrative claims and electronic medical records of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between January 1, 2008 and December 31, 2008. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables include physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. We used multivariable logistic regression to identify the independent association of physician and patient characteristics with ordering of laboratory tests to monitor medications after adjustment for potential confounders, taking into account clustering of drugs within patients and patients within providers. Results Physician orders for laboratory testing varied across drug-test pairs and ranged from 9% (Primidone–Phenobarbital level) to 97% (Azathioprine–CBC) with 50% of drug-test pairs in the 85-91% ordered range. Failure to order a test was associated with lower provider prescribing volume for study drugs and whether the physician was a specialist (primary care providers were more likely to order tests than specialists). Patients with lower patient comorbidity burden and younger patients were less likely to have appropriate tests ordered. Drug-test combinations with black box warnings were more likely to have tests ordered. Conclusions Interventions targeting providers should be addressed at those subgroups with the greatest potential for improvement: providers with lower frequencies of prescribing high-risk medications, and healthier and younger patients. Drug-test combinations with black box warnings have higher ordering rates, but many medications without such warnings also have evidence of harm, thus efforts to improve testing are necessary for all medications shown to be high-risk

Age, Multiple Chronic Conditions, and COVID-19: A literature review

BACKGROUND: Various patient demographic and clinical characteristics have been associated with poor outcomes for individuals with coronavirus disease 2019 (COVID-19). To describe the importance of age and chronic conditions in predicting COVID-19 related outcomes. METHODS: Search strategies were conducted in PubMed/MEDLINE. Daily alerts were created. RESULTS: A total of 28 studies met our inclusion criteria. Studies varied broadly in sample size (n=21 to more than 17,000,000). Participants mean age ranged from 48 years to 80 years and the proportion of male participants ranged from 44%-82%. The most prevalent underlying conditions in patients with COVID-19 were hypertension (range: 15% - 69%), diabetes (8% - 40%), cardiovascular disease (4% - 61%), chronic pulmonary disease (1% - 33%), and chronic kidney disease (range 1% - 48%). These conditions were each associated with an increased in-hospital case fatality rate ranging from 1% to 56%. Overall, older adults have a substantially higher case fatality rate (CFR) as compared with younger individuals affected by COVID-19 (42% for those \u3c 65 vs 65% \u3e 65 years ). Only one study examined the association of chronic conditions and the risk of dying across different age groups; their findings suggested similar trends of increased risk in those \u3c 65 and those \u3e 65 years as compared to those without these conditions. CONCLUSIONS: There has been a traditional, single condition approach to consideration of how chronic conditions and advancing age relate to COVID-19 outcomes. A more complete picture of the impact of burden of multimorbidity and advancing patient age is needed

Temporal trends in cardiogenic shock complicating acute myocardial infarction

BACKGROUND: Limited information is available on trends in the incidence of and mortality due to cardiogenic shock complicating acute myocardial infarction. We studied the incidence of cardiogenic shock complicating acute myocardial infarction and in-hospital death rates among patients with this condition in a single community from 1975 through 1997. METHODS: We conducted an observational study of 9076 residents of metropolitan Worcester, Massachusetts, who were hospitalized with confirmed acute myocardial infarction in all local hospitals during 11 one-year periods between 1975 and 1997. Our study included periods before and after the advent of reperfusion therapy. RESULTS: The incidence of cardiogenic shock remained relatively stable over time, averaging 7.1 percent among patients with acute myocardial infarction. The results of a multivariable regression analysis indicated that the patients hospitalized during recent study years were not at a substantially lower risk for shock than patients hospitalized in the mid-to-late 1970s. Patients in whom cardiogenic shock developed had a significantly greater risk of dying during hospitalization (71.7 percent) than those who did not have cardiogenic shock (12.0 percent, P\u3c0.001). A significant trend toward an increase in in-hospital survival among patients with cardiogenic shock in the mid-to-late 1990s was found in crude and adjusted analyses. CONCLUSIONS: Our findings indicate no significant change in the incidence of cardiogenic shock complicating acute myocardial infarction over a 23-year period. However, the short-term survival rate has increased in recent years at the same time as the use of coronary reperfusion strategies has increased