Cardiovascular disease care in the nursing home: the need for better evidence for outcomes of care and better quality for processes of care.

Poor quality of care is not equal opportunity and disproportionately affects vulnerable segments of the population.1-3 As one of the most vulnerable patient populations, nursing home residents often receive poor quality care.4-9 Nursing home quality of care has traditionally focused on nursing-intensive cares such as physical activities, restraints, falls, pressure ulcers, weight loss, and vaccination. The Center for Medicare and Medicaid Services (CMS) has developed indicators to measure quality of these cares in the nursing home. However, there is currently no such indicator to measure quality of chronic disease care in the nursing home. Chronic cardiovascular disease is common among nursing home residents.10 Nursing home residents with chronic cardiovascular disease are frequently referred to emergency rooms during episodes of acute exacerbation and many are eventually hospitalized. However, a large number of these patients often do not receive proper care during hospital stay and discharge. This is puzzling as these frail elderly nursing home residents often endure the delays and deliriums of emergency departments and hospital rooms and yet may not receive the necessary standard of care! In one study of hospitalized acute heart failure patients, 9% of patients were nursing home residents.5 In that study, only about 40% of nursing home residents with heart failure had their left ventricular function evaluated, and among those with systolic heart failure who were eligible for angiotensin-converting enzyme inhibitors, only 50% were prescribed those drugs. These rates were significantly lower than the rates for those admitted from the community. Evaluation of left ventricular ejection fraction and use of angiotensin-converting enzyme inhibitors are CMS quality indicators for heart failure.5 Nursing home residents with heart failure were being hospitalized during acute exacerbation, yet they were not prescribed recommended evidence-based therapy that could potentially reduce mortality and rehospitalization. For patients hospitalized with acute myocardial infarction, use of aspirin and beta-blockers are considered quality indicators by the CMS. However, findings from a national study of Medicare fee-for-service beneficiaries during 1997-1999 indicated that only 72% of eligible patients were receiving prescription for beta-blockers during hospital discharge.11 Data from the National Cooperative Cardiovascular Project based on 115,015 patients 65 years and older hospitalized with a confirmed acute myocardial infarction during 1994-1995 indicated that only 50% of the 45,308 eligible patients were prescribed a beta-blocker before hospital discharge.12 In this latter study, the use of beta-blockers was associated with a significant 14% decrease in 1-year mortality (unadjusted risk ratio, 0.59; 95% confidence interval, 0.56 – 0.63; P <0.0001). The association between beta-blocker use and 1-year mortality remained significant (adjusted risk ratio, 0.86; 95% confidence interval, 0.80 – 0.91; P <0.0001) after adjustment for demographic, clinical presentation, hospital course, and discharge medication variables.12 The higher rates (72%) reported by Jencks et al. (based on 1997-1999 data) than those (50%) reported by Krumholz et al. (based on 1994-1995 data) may be a reflection of temporal improvement in quality of care of acute myocardial infarction and variations in study methodologies.11 Levy et al analyzed the National Cooperative Cardiovascular Project datasets and reported their findings on the quality and outcomes of care of nursing home residents with acute myocardial infarction in the current issue of the journal.13 Unlike the parent study by Krumholz et al. which was based on 115,015 patients, the current study is based on 127,163 patients, which may be due to variations in the inclusion / exclusion criteria used in these two studies. The authors report that 61% of all eligible patients with acute myocardial infarction received “early” beta-blockers during hospital stay but only 44% of the nursing home residents received these drugs during the same period. The overall 61% rate of early beta-blocker use reported in this study is higher than the rate of 50% discharge use of beta-blockers reported by Krumholz et al in the same cohort.12 This is unlikely due to variations in the timing of beta-blocker use (early use by Levy et al and discharge use by Krumholz et al) between the two studies. The rate of beta-blocker use within 24 hours of hospital admission has been reported to be lower than that during hospital discharge.11, 14 Levy et al. also reported a similar underuse of aspirin in nursing home residents with acute myocardial infarction. It is unknown to what extent the underuse of these essential life-saving drugs may have been caused by biases associated with imbalances in baseline characteristics. Findings from the Table 1 of the current report demonstrate that compared to patients admitted from the community, those admitted form a nursing home were more likely to be older and have higher disease and comorbidity burden.13 Levy et al. also reported that the “early” use of beta-blockers in hospitalized nursing home residents with acute myocardial infarction was associated with significant reduction in unadjusted 30-day and 1-year mortalities.13 Unadjusted 1-year mortality occurred in 38% and 55% of nursing home residents respectively receiving and not receiving beta-blockers (P <0.0001). Similar association between aspirin use and mortality was also observed. Even though the authors did not present data on baseline characteristics for nursing home residents receiving and not receiving beta-blockers or aspirin, it is likely that nursing home residents who were prescribed these drugs were younger with fewer comorbidities and lesser disease burden. It is unknown to what extent these imbalances in baseline characteristics may explain the lower mortality associated with the use of these drugs. Data from the parent Cooperative Cardiovascular Project indicate that the morality reduction associated with the use of these two drugs remained significant after multivariable risk adjustment.12, 15 The authors could have saved the readers from making these assumptions and extrapolations by performing multivariable regression-based risk adjustments as done in the parent studies.12, 15 They also could have given the readers a preview of the balance or lack thereof in baseline characteristics of nursing home residents receiving and not receiving aspirin and beta-blockers. The presentation of the baseline characteristics data was made complicated by the authors' study of more than one drug or therapy in their study. This could have been simplified by presenting baseline data separately by aspirin and beta-blocker use, or by analyzing them separately as done in the parent studies.12, 15 Recently, propensity score matching has emerged as powerful tool with which to design non-randomized studies.16-18 Unlike traditional regression-based multivariable risk adjustment, propensity-matched studies can be designed while remaining blinded to study outcomes thus mimicking one key feature of randomized clinical trials (Figure 1).17 In addition, covariate imbalances before and after study design can be objectively measured and presented using visually pleasant graphics.18-21 Because many of the clinical questions involving nursing home residents may not be answered from evidence derived from randomized clinical trials, it is essential to use stringent study designs such as propensity matching to derive the best evidence for nursing home residents that non-randomized studies can provide. When randomized clinical trials are not logistically feasible and/or ethically unjustifiable, non-randomized studies using rigorous methodology may provide evidence for clinical practice.22 Figure 1 Comparing designs for randomized clinical trials, propensity-matched studies, and regression-based multivariable risk-adjusted studies. In regression-based multivariable risk-adjusted studies, the line between study design and events is blurred and the ... While investigators improve their design for non-randomized studies of outcomes of care involving nursing home residents, it is important that clinicians continue their efforts to improve processes of care for hospitalized nursing home residents. If we make a frail elderly nursing home resident to go through the near-traumatic and at times life-changing experience of hospitalization, then we are also obligated to provide them the standard of care that is received by other hospitalized patients. Individual exceptions are expected and should be well documented in charts. We should treat our nursing home residents in the same manner we would like ourselves, our parents and our grandparents to be treated. We need to keep in mind that our practice will set the precedence for future generations of clinicians who will treat us should we live long enough…!