The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions.

BACKGROUND: Accountable care organizations (ACOs) and the employment of nurse practitioners (NP) in place of physicians are strategies that aim to reduce the cost and improve the quality of routine care delivered in skilled nursing facilities (SNF). The recent expansion of ACOs and nurse practitioners into SNF settings in the United States may be associated with improved health outcomes for patients. OBJECTIVES: To determine the relationship between ACO attribution and NP care delivery during SNF visits and the relationship between NP care delivery during SNF visits and unplanned hospital readmissions. METHODS: We obtained a sample of 527,329 fee-for-service Medicare beneficiaries with 1 or more SNF stays between 2012 and 2017. We used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management services delivered by NPs and hospital readmissions. RESULTS: ACO beneficiaries were 1.26% points more likely to receive 1 or more E&M services delivered by an NP during their SNF visits [Marginal Effect (ME): 0.0126; 95% CI: (0.009, 0.0160)]. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001). CONCLUSIONS: Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. ACOs attributed beneficiaries were more likely to obtain the benefits of greater nurse practitioner involvement in their care.

Patient Cognitive Status and Physician Recommendations for Cardiovascular Disease Treatment: Results of Two Nationwide, Randomized Survey Studies.

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.

Influence of mild cognitive impairment on patient and care partner decision-making for acute ischemic stroke.

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.

The Association Between Mild Cognitive Impairment Diagnosis and Patient Treatment Preferences: a Survey of Older Adults.

BACKGROUND: Older patients (65+) with mild cognitive impairment (MCI) receive less guideline-concordant care for cardiovascular disease (CVD) and other conditions than patients with normal cognition (NC). One potential explanation is that patients with MCI want less treatment than patients with NC; however, the treatment preferences of patients with MCI have not been studied. OBJECTIVE: To determine whether patients with MCI have different treatment preferences than patients with NC. DESIGN: Cross-sectional survey conducted at two academic medical centers from February to December 2019 PARTICIPANTS: Dyads of older outpatients with MCI and NC and patient-designated surrogates. MAIN MEASURES: The modified Life-Support Preferences-Predictions Questionnaire score measured patients' preferences for life-sustaining treatment decisions in six health scenarios including stroke and acute myocardial infarction (range, 0-24 treatments rejected with greater scores indicating lower desire for treatment). KEY RESULTS: The survey response rate was 73.4%. Of 136 recruited dyads, 127 (93.4%) completed the survey (66 MCI and 61 NC). The median number of life-sustaining treatments rejected across health scenarios did not differ significantly between patients with MCI and patients with NC (4.5 vs 6.0; P=0.55). Most patients with MCI (80%) and NC (80%) desired life-sustaining treatments in their current health (P=0.99). After adjusting for patient and surrogate factors, the difference in mean counts of rejected treatments between patients with MCI and patients with NC was not statistically significant (adjusted ratio, 1.08, 95% CI, 0.80-1.44; P=0.63). CONCLUSION: We did not find evidence that patients with MCI want less treatment than patients with NC. These findings suggest that other provider and system factors might contribute to patients with MCI getting less guideline-concordant care.

Preexisting Mild Cognitive Impairment, Dementia, and Receipt of Treatments for Acute Ischemic Stroke.

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.

Patient and Care Partner Perspective on Potential Undertreatment of Patients With Mild Cognitive Impairment for Cardiovascular Disease.

BACKGROUND AND OBJECTIVES: Mild cognitive impairment (MCI) affects up to 22% of US older adults aged 65 and older. Research suggests that physicians may recommend less cardiovascular disease (CVD) treatment for older adults with MCI due to assumptions about their preferences. To delve into the disparity between patient preferences and physician assumptions in CVD treatment recommendations, we conducted a multi-site qualitative study to explore the underlying reasons for this discrepancy, providing insights into potential communication barriers and strategies to enhance patient-physician relationships. RESEARCH DESIGN AND METHODS: Employing a descriptive qualitative approach, we conducted interviews with 20 dyads, comprising older adults with MCI (n = 11) and normal cognition NC (n = 9), and their respective care partners. During these interviews, participants were prompted to reflect on physicians recommending fewer guideline-concordant CVD treatments to older adults with MCI than those with NC and physicians presuming that older adults with MCI desired less care or treatment in general than those with NC. RESULTS: We identified three primary themes: (1) Most participants had negative reactions to the data that physicians might undertreat patients with MCI for CVD; (2) Participants suggested that physicians may undertreat patients with MCI due to physician assumptions about treatment effectiveness, patient prognosis, value, and treatment adherence, and (3) Participants proposed that physicians may elicit less input from patients with MCI about treatments because of negative physician assumptions about patient decision-making capacity and physician time limitations. DISCUSSION AND IMPLICATIONS: This study underscores the pressing need for person-centered communication and involvement of older adults with MCI and their care partners in the decision-making process to ensure that decisions are well-informed, reflecting patients' genuine preferences and values. Addressing these concerns has the potential to substantially enhance the quality of care and treatment outcomes for this vulnerable population, ultimately promoting their overall well-being.

Perspectives on Why Patients with Mild Cognitive Impairment Might Receive Fewer Cardiovascular Disease Treatments than Patients with Normal Cognition.

BACKGROUND: People with mild cognitive impairment (MCI) receive fewer guideline-concordant treatments for cardiovascular disease (CVD) than people with normal cognition (NC). OBJECTIVE: To understand physician perspectives on why patients with MCI receive fewer CVD treatments than patients with NC. METHODS: As part of a mixed-methods study assessing how patient MCI influences physicians' decision making for acute myocardial infarction (AMI) and stroke treatments, we conducted a qualitative study using interviews of physicians. Topics included participants' reactions to data that physicians recommend fewer CVD treatments to patients with MCI and reasons why participants think fewer CVD treatments may be recommended to this patient population. RESULTS: Participants included 22 physicians (8 cardiologists, 7 neurologists, and 7 primary care physicians). Most found undertreatment of CVD in patients with MCI unreasonable, while some participants thought it could be considered reasonable. Participants postulated that other physicians might hold beliefs that could be reasons for undertreating CVD in patients with MCI. These beliefs fell into four main categories: 1) patients with MCI have worse prognoses than NC, 2) patients with MCI are at higher risk of treatment complications, 3) patients' cognitive impairment might hinder their ability to consent or adhere to treatment, and 4) patients with MCI benefit less from treatments than NC. CONCLUSION: These findings suggest that most physicians do not think it is reasonable to recommend less CVD treatment to patients with MCI than to patients with NC. Improving physician understanding of MCI might help diminish disparities in CVD treatment among patients with MCI.

Physician Diagnosis and Knowledge of Mild Cognitive Impairment.

BACKGROUND: Older adults with mild cognitive impairment (MCI) receive fewer guideline-concordant treatments for multiple health conditions than those with normal cognition. Reasons for this disparity are unclear. OBJECTIVE: To better understand this disparity, we describe physician understanding and experience with patient MCI, particularly physician identification of MCI, ability to distinguish between MCI and dementia, and perspectives on education and training in MCI and dementia. METHODS: As part of a mixed-methods study assessing the influence of patient MCI on physician recommendations for acute myocardial infraction and stroke treatments, we conducted a descriptive qualitative study using semi-structured interviews of physicians from three specialties. Key question topics included participants' identification of MCI, impressions of MCI and dementia awareness within their practice specialty, and perspectives on training and education in MCI. RESULTS: The study included 22 physicians (8 cardiologists, 7 neurologists, and 7 internists). We identified two primary themes: There is 1) a lack of adequate understanding of the distinction between MCI and dementia; and 2) variation in physician approaches to identifying whether an older adult has MCI. CONCLUSION: These findings suggest that physicians have a poor understanding of MCI. Our results suggest that interventions that improve physician knowledge of MCI are needed.

A Mixed-Methods Study of the Impact of Mild Cognitive Impairment Diagnosis on Patient and Care Partner Perception of Health Risks.

BACKGROUND: Older patients (≥65 years) with mild cognitive impairment (MCI) are undertreated for cardiovascular disease (CVD). One reason for this disparity could be that patients with MCI might underestimate the chances of CVD and overestimate dementia. OBJECTIVE: To compare conceptions of health risk between older patients with MCI and normal cognition (NC) and their care partners. METHODS: We conducted a multi-center mixed-methods study of patient-care partner dyads completing written quantitative surveys (73% response rate; 127 dyads: 66 MCI and 61 NC) or semi-structured interviews (20 dyads: 11 MCI, and 9 NC). Surveys assessed two-year patient risks of dementia, heart attack, stroke, and fall. Interviews assessed similar health risks and reasons for risk perceptions. RESULTS: On surveys, a similarly low proportion of MCI and NC patients felt they were at risk of stroke (5% versus 2%; p = 0.62) and heart attack (2% versus 0%; p = 0.99). More MCI than NC patients perceived dementia risk (26% versus 2%; p < 0.001). Care partners' survey findings were similar. Interviews generally confirmed these patterns and also identified reasons for future health concerns. For both MCI and NC dyads, personal experience with cognitive decline or CVD (personal or family history) increased concerns about each disease. Additionally, perceptions of irreversibility and lack of treatment for cognitive decline increased concern about dementia. CONCLUSION: Less use of CVD treatments in MCI seems unlikely to be driven by differential perceptions of CVD risk. Future work to improve awareness of CVD risks in older patients and dementia risk in patients with MCI are warranted.

Impact of Patient Mild Cognitive Impairment on Physician Decision-Making for Treatment.

BACKGROUND: Older patients with mild cognitive impairment (MCI) should receive evidence-based treatments when clinically indicated. However, patients with MCI appear less likely than cognitively normal patients to receive evidence-based treatments. OBJECTIVE: To explore the influence of a patient's MCI diagnosis on physician decision-making. METHODS: Qualitative study of 18 physicians from cardiology, neurology, and internal medicine using semi-structured interviews. We sought to understand whether and how a patient's having MCI has influenced physicians' decisions about five categories of treatments or tests (surgery, invasive tests, non-invasive tests, rehabilitation, and preventive medication). We used qualitative content analysis to identify the unifying and recurrent themes. RESULTS: Most physician participants described MCI as influencing their recommendations for at least one treatment or test. We identified two major themes as factors that influenced physician recommendations in patients with MCI: Physicians assume that MCI patients' decreased cognitive ability will impact treatment; and physicians assume that MCI patients have poor health status and physical functioning that will impact treatment. These two themes were representative of physician beliefs that MCI patients have impaired independent decision-making, inability to adhere to treatment, inability to communicate treatment preferences, and increased risk and burden from treatment. CONCLUSION: A patient's MCI diagnosis influences physician decision-making for treatment. Some physician assumptions about patients with MCI were not evidence-based. This phenomenon potentially explains why many patients with MCI get fewer effective treatments or tests than cognitively normal patients. Interventions that improve how physicians understand MCI and make decisions for treatments in patients with MCI are needed.

Association of Medication Nonadherence Among Adult Survivors of Stroke After Implementation of the US Affordable Care Act.

Importance: Among adults with chronic disease, survivors of stroke have high out-of-pocket financial burdens. The US government enacted the Affordable Care Act (ACA) in 2010 and implemented the law in 2014 to provide more low-income adults with health insurance coverage. Objective: To assess whether ACA implementation is associated with cost-related nonadherence (CRN) to medication among adult survivors of stroke. Design, Setting, and Participants: This study analyzed data from the 2000 to 2016 National Health Interview Survey, an in-person household survey of the noninstitutionalized US population conducted annually by the National Center for Health Statistics. Conducted at the University of Michigan Medical School, Ann Arbor, from July 24, 2017, to February 28, 2018, the study had a sample of 13 930 survivors of stroke. Analyses were stratified by age (45-64 years vs ≥65 years). Time was treated as a continuous variable and as a categorical variable across 4 periods (2000-2005, historical control; 2006-2010, economic recession and peak unemployment; 2011-2013, before ACA implementation; and 2014-2016, after ACA implementation). Percentages are weighted to reflect US population estimates. Main Outcomes and Measures: The primary outcome was the self-report of CRN, defined as the inability to afford prescribed medications within the past 12 months. Results: Among the 13 930 total survivors of stroke, 38.1% were aged 45 to 64 years (50.5% were female and 49.5% were male, with a mean [SE] age of 56.0 [0.10] years), and 61.9% were aged 65 years or older (54.9% were female and 45.1% were male, with a mean [SE] age of 76.2 [0.09] years). From 2011 to 2013 through 2014 to 2016, Medicaid increased (from 24.0% [95% CI, 21.0%-27.2%] in 2011-2013 to 30.8% [95% CI, 27.3%-34.6%] in 2014-2016; P < .001) and uninsurance decreased (from 13.7% [95% CI, 11.3%-16.4%] to 6.8% [95% CI, 5.3%-8.8%]; P < .001) among survivors of stroke aged 45 to 64 years. Among survivors aged 45 to 64 years, CRN increased over time before ACA implementation (from 18.6% [95% CI, 16.5%-20.9%] in 2000-2005, to 22.6% [95% CI, 19.7%-25.9%] in 2006-2010, to 23.8% [95% CI, 20.7%-27.3%] in 2011-2013) and decreased after ACA implementation to 18.1% (95% CI, 15.4%-21.3%; P = .01) in 2014 to 2016. The period after ACA implementation was associated with lower odds of CRN after adjustment for sociodemographics, year, and clinical factors (odds ratio [OR], 0.63; 95% CI, 0.47-0.85). The difference was attenuated after further adjustment for health insurance coverage (OR, 0.76; 95% CI, 0.56-1.03). Conclusions and Relevance: After the ACA implementation, health insurance coverage increased and CRN decreased among adult survivors of stroke, suggesting that further expansion of Medicaid coverage is likely to be advantageous for survivors.