Older adult preferences regarding benefits and harms of statin and aspirin therapy for cardiovascular primary prevention

OBJECTIVE Personalizing preventive therapies for atherosclerotic cardiovascular disease (ASCVD) is particularly important for older adults, as they tend to have multiple chronic conditions, increased risk for medication adverse effects, and may have heterogenous preferences when weighing health outcomes. However, little is known about outcome preferences related to ASCVD preventive therapies in older adults. METHODS In May 2021, using an established online panel, KnowledgePanel, we surveyed older US adults aged 65-84 years without history of ASCVD on outcome preferences related to statin therapy (benefit outcomes to be reduced by the therapy: heart attack, stroke; adverse effects: diabetes, abnormal liver test, muscle pain) or aspirin therapy (benefit outcomes: heart attack, stroke; adverse effects: brain bleed, bowel bleed, stomach ulcer). We used standardized best-worst scores (range of -1 for "least worrisome" to +1 for "most worrisome") and conditional logistic regression to examine the relative importance of the outcomes. RESULTS In this study, 607 ASCVD-free participants (median age 74, 46% male, 81% White) were included; 304 and 303 completed the statin and aspirin versions of the survey, respectively. For statin-related outcomes, stroke and heart attack were most worrisome (score 0.55; 95% CI 0.51, 0.60) and (0.53; 0.48, 0.58), followed by potential harms of diabetes (-0.07; -0.10, -0.03), abnormal liver test (-0.25; -0.29, -0.20), and muscle pain (-0.77; -0.82, -0.73). For aspirin-related outcomes, stroke and heart attack were similarly most worrisome (0.48; 0.43, 0.52) and (0.43; 0.38, 0.48), followed by brain bleed (0.30; 0.25, 0.34), bowel bleed (-0.31; -0.33, -0.28), and stomach ulcer (-0.90; -0.92, -0.87). Conditional logistic regression and subgroup analyses by age, sex, and race yielded similar results. CONCLUSIONS Older adults generally consider outcomes related to benefits of ASCVD primary preventive therapies-stroke and heart attack-more important than their adverse effects. Integrating patient preferences with risk assessment is an important next step for personalizing ASCVD preventive therapies for older adults

Harm and Medication-Type Impact Agreement with Hypothetical Deprescribing Recommendations: a Vignette-Based Experiment with Older Adults Across Four Countries

BACKGROUND: Little is known about what factors are important to older adults when deciding whether to agree with a recommendation to deprescribe. OBJECTIVE: To explore the extent to which medication type and rationale for potential discontinuation influence older adults' acceptance of deprescribing. DESIGN: Cross-sectional 2 (drug: lansoprazole - treat indigestion; simvastatin - prevent cardiovascular disease) by 3 (deprescribing rationale: lack of benefit; potential for harm; both) experimental design. PARTICIPANTS: Online panelists aged ≥65 years from Australia, the Netherlands, the United Kingdom, and the United States INTERVENTIONS: Participants were presented with a hypothetical patient experiencing polypharmacy whose PCP discussed stopping a medication. We randomized participants to receive one of six vignettes. MAIN MEASURES: We measured agreement with deprescribing (6-point Likert scale, "Strongly disagree (1)" and "Strongly agree (6)") for the hypothetical patient as the primary outcome. We also measured participants' personality traits, perceptions of risk and uncertainty, and attitudes towards polypharmacy and deprescribing. KEY RESULTS: Among 5311 participants (93.3% completion rate), the mean (M) agreement with deprescribing for the hypothetical patient was 4.71 (95% confidence interval (CI): 4.67, 4.75). Participants reported higher agreement with stopping lansoprazole (n=2656) (M=4.90, 95% CI: 4.85, 4.95) compared to simvastatin (n=2655) (M=4.53, 95% CI: 4.47, 4.58), P<.001. Participants who received the combination rationale (n=1786) reported higher agreement with deprescribing (M=4.83, 95% CI: 4.76, 4.89) compared to those who received the rationales on lack of benefit (n=1755) (M=4.66, 95% CI: 4.60, 4.73) or potential for harm (n=1770) (M=4.65, 95% CI 4.58, 4.72). In adjusted regression analyses (n=5062), participants with a higher desire to engage in health promotion behaviors (b=0.08, 95% CI 0.02, 0.13) or need for certainty (b=0.12, 95% CI 0.04, 0.20) reported higher agreement with deprescribing. CONCLUSIONS: Older adults across four countries were accepting of deprescribing in the setting of polypharmacy. The medication type and rationale for discontinuation were important factors in the decision-making process. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04676282, https://clinicaltrials.gov/ct2/show/NCT04676282?term=vordenberg&draw=2&rank=1

Primary care clinicians’ perceptions of colorectal cancer screening tests for older adults

Colonoscopy is an effective screening test for colorectal cancer but is associated with significant risks and burdens, especially in older adults. Stool tests, which are more convenient, more accessible, and less invasive, can be important tools to improve screening. How clinicians make decisions about colonoscopy versus stool tests in older patients is not well-understood.We conducted semi-structured interviews with primary care clinicians throughout Maryland in 2018–2019 to examine how clinicians considered the use of stool tests for colorectal cancer screening in their older patients. Thirty clinicians from 21 clinics participated. The mean clinician age was 48.2 years. The majority were physicians (24/30) and women (16/30). Four major themes were identified using qualitative content analysis: (1) Stool test equivalency - although many clinicians still considered colonoscopy as the test of choice, some clinicians considered stool tests equivalent options for screening. (2) Reasons for recommending stool tests – clinicians reported preferentially using stool tests in sicker/older patients or patients who declined colonoscopy. (3) Stool test overuse – some clinicians reported recommending stool tests for patients for whom guidelines do not recommend any screening. (4) Barriers to use – perceived barriers to using stool tests included lack of familiarity, un-returned stool test kits, concern for accuracy, and concern about cost.In summary, clinicians reported preferentially using stool tests in sicker and older patients and mentioned examples of potential overuse. Additional studies are needed on how to better individualize the use of different colorectal screening tests in older patients

Harm and Medication-Type Impact Agreement with Hypothetical Deprescribing Recommendations: a Vignette-Based Experiment with Older Adults Across Four Countries.

BACKGROUND Little is known about what factors are important to older adults when deciding whether to agree with a recommendation to deprescribe. OBJECTIVE To explore the extent to which medication type and rationale for potential discontinuation influence older adults' acceptance of deprescribing. DESIGN Cross-sectional 2 (drug: lansoprazole - treat indigestion; simvastatin - prevent cardiovascular disease) by 3 (deprescribing rationale: lack of benefit; potential for harm; both) experimental design. PARTICIPANTS Online panelists aged ≥65 years from Australia, the Netherlands, the United Kingdom, and the United States INTERVENTIONS: Participants were presented with a hypothetical patient experiencing polypharmacy whose PCP discussed stopping a medication. We randomized participants to receive one of six vignettes. MAIN MEASURES We measured agreement with deprescribing (6-point Likert scale, "Strongly disagree (1)" and "Strongly agree (6)") for the hypothetical patient as the primary outcome. We also measured participants' personality traits, perceptions of risk and uncertainty, and attitudes towards polypharmacy and deprescribing. KEY RESULTS Among 5311 participants (93.3% completion rate), the mean (M) agreement with deprescribing for the hypothetical patient was 4.71 (95% confidence interval (CI): 4.67, 4.75). Participants reported higher agreement with stopping lansoprazole (n=2656) (M=4.90, 95% CI: 4.85, 4.95) compared to simvastatin (n=2655) (M=4.53, 95% CI: 4.47, 4.58), P<.001. Participants who received the combination rationale (n=1786) reported higher agreement with deprescribing (M=4.83, 95% CI: 4.76, 4.89) compared to those who received the rationales on lack of benefit (n=1755) (M=4.66, 95% CI: 4.60, 4.73) or potential for harm (n=1770) (M=4.65, 95% CI 4.58, 4.72). In adjusted regression analyses (n=5062), participants with a higher desire to engage in health promotion behaviors (b=0.08, 95% CI 0.02, 0.13) or need for certainty (b=0.12, 95% CI 0.04, 0.20) reported higher agreement with deprescribing. CONCLUSIONS Older adults across four countries were accepting of deprescribing in the setting of polypharmacy. The medication type and rationale for discontinuation were important factors in the decision-making process. TRIAL REGISTRATION ClinicalTrials.gov , NCT04676282, https://clinicaltrials.gov/ct2/show/NCT04676282?term=vordenberg&draw=2&rank=1

Innovative Strategies to Facilitate Patient-Centered Research in Multiple Chronic Conditions.

Multiple chronic conditions (MCC) are one of today's most pressing healthcare concerns, affecting 25% of all Americans and 75% of older Americans. Clinical care for individuals with MCC is often complex, condition-centric, and poorly coordinated across multiple specialties and healthcare services. There is an urgent need for innovative patient-centered research and intervention development to address the unique needs of the growing population of individuals with MCC. In this commentary, we describe innovative methods and strategies to conduct patient-centered MCC research guided by the goals and objectives in the Department of Health and Human Services MCC Strategic Framework. We describe methods to (1) increase the external validity of trials for individuals with MCC; (2) study MCC epidemiology; (3) engage clinicians, communities, and patients into MCC research; and (4) address health equity to eliminate disparities

Demographic, health, and attitudinal factors predictive of cancer screening decisions in older adults

Many older adults receive routine cancer screening even when it is no longer recommended. We sought to identify demographic, health-related, and attitudinal factors that are most predictive of continued breast, colorectal, and prostate cancer screening decisions in older adults under various scenarios. A sample of adults age 65+ (n = 1272) were recruited from a nationally representative panel in November 2016, of which 881 (69.3%) completed our survey. Participants were presented vignettes in which we experimentally varied a hypothetical patient's life expectancy, age, quality of life, and physician screening recommendation. The dependent variable was the choice to continue cancer screening in the vignette. Classification and regression tree (CART) analysis was used to identify characteristics most predictive of screening decisions; both the participants' characteristics and the hypothetical patient's characteristics in the vignettes were included in the analysis. CART analysis uses recursive partitioning to create a classification tree in which variables predictive of the outcome are included as hierarchical tree nodes. We used automated ten-fold cross-validation to select the tree with lowest misclassification and highest predictive accuracy. Participants' attitude towards cancer screening was most predictive of choosing screening. Among those who agreed with the statement “I plan to get screened for cancer for as long as I live” (n = 300, 31.9%), 73.2% chose screening and 57.2% would still choose screening if hypothetical patient had 1-year life expectancy. For this subset of older adults with enthusiasm towards screening even when presented with scenario involving limited life expectancy, efforts are needed to improve informed decision-making about screening. Keywords: Cancer screening, Life expectancy, Decision-making, CART analysi

L'EU appelle à une réduction de 60% des soutiens distorsifs

Suite à la réunion 'mini-ministérielle' de Montréal, le Commissaire européen à l'agriculture, Franz Fischler a affirmé, le 30 juillet 2003, que l'UE était prête à engager une réduction importante de 60% de ses soutiens intérieurs distorsifs', à éliminer 'les subventions à l'exportation pour certains produits' et à les réduire pour les autres. Toutefois ceci est conditionné à la mise en oe uvre de mesures équivalentes pour d'autre formes de soutiens à l'exportation. Le Commissaire Fischler a également réaffirmé la volonté de l'UE de réduire les tarifs douaniers de 36% en moyenne et manifesté la volonté 'd'ouvrir ou d'étendre les quotas pour certains produits sensibles'. Il a aussi plaidé pour une meilleure protection des produits de qualité et pour plus de concession sur les questions non commerciales. Il a enfin réitéré l'appel à tous les pays développés pour qu'ils accordent un accès libre de droits et de quotas aux exportations provenant des pays les moins avancés. Comment: La volonté de l'UE de réduire de 60% les soutiens intérieurs distorsifs est en effet conditionnée par l'acceptation par l'OMC des systèmes de soutien de l'UE pour traiter les questions non commerciale, c'est à dire une acceptation internationale de la définition de l'UE des formes de soutien non distorsives. Une telle approbation conduira bien sur à un retrait de toute sanction pour ce type de soutien, qui se développe actuellement dans le cadre de la réforme de la PAC. Les projections de l'USDA sur l'impact budgétaire des propositions originales de l'UE pour la réforme de la PAC montrent une réduction de 55% des dépenses sur les mesures liées aux marchés. Si on y ajoute les autres réformes en attente, l'UE devrait pouvoir atteindre ses objectifs dans le cadre de la construction actuelle de la réforme de la PAC.Suite à la réunion 'mini-ministérielle' ..

Additional file 1: of Incorporating prognosis in the care of older adults with multimorbidity: description and evaluation of a novel curriculum

Incorporating Prognosis in the Care of Older Adults with Multimorbidity - Prognostic Resources. (DOCX 834 kb