Outline. Clinical Characteristics VA N=13, Midwest N=57,864. Northeast N=39,405. South N=63,137.

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1 Outline Heart Failure in the Nursing Home Evelyn Hutt MD Geriatric Grand Rounds University of Colorado Denver January 2011 Prevalence and demographics Clinical characteristics Outcomes Preserved versus reduced EF - does it matter? How useful are the standard treatments (e.g., ) for impacting mortality and hospitalization in this setting? How useful are the standard treatments for the outcomes that matter in nursing homes? Function Quality of Life Palliative Care for heart failure the new frontier Epidemiology 1of 6 patients hospitalized with HF are discharged to NH 50% of HF pts discharged to NH rehospitalized within 6 months Prevalence of HF in NH = 20-40% Medicare population - 40% VA population - 30% Demographics Clinical Characteristics Outcomes Northeast N=39,405 Midwest N=57,864 West N=26,914 South N=63,137 VA N=13,147 Age (years) Female African American Hispanic Asian Comorbidity Index Northeast N=39,405 Midwest N=57,864 West N=26,914 South N=63,137 VA N=13, Average Barthel Score Cognitive Performance Score Percent in NH<90 days Annual Mortality Rate Heart Failure Hospitalization Medicare VA

2 Preserved Versus Reduced Ejection Fracture Does it matter? Total VA cohort n=13147 VA echo cohort, n=294 % Male Average Age % African American %Hispanic Average Comorbidity index In multiple logistic regression, preserved versus reduced ejection fraction did not predict either hospitalization or mortality. Average Barthel Score What about Medications? Objective Assess the association between prescription and subsequent mortality and HF hospitalization in a national sample of VA nursing home (community living center CLC) residents with HF. Methods Using variables found in VA National Data System (NDS) describe Demographics Baseline functional and cognitive status Biochemical markers»sodium»creatinine»hemoglobin Comorbidity Facility characteristics Medications 2

3 Methods Compare subjects who received prescription to those who did not Develop propensity score for prescription using logistic regression on age gender race BMI Barthel index CPS history of depression comorbidities length of CLC stay advanced directives Na, Hgb, Creat. facility variables Match patients by propensity score on baseline exposure to Cohort Selection 64,272 veterans admitted to CLCs FY 2003 and ,693 not in respite care and age >65 13,147 (32%) in- or out-patient HF dx by JCAHO/CMS ICD9 code 7,368 matched on prescription propensity prescribed not prescribed 7,221 (45%) 5,926 (55%) Analysis Assess association between prescription and the adverse outcomes of Mortality HF rehospitalization using Cox Proportional Hazard Methods to adjust for Age Gender Comorbidity index Na Hgb Creat. Barthel index CPS Depression Other HF meds Advance Directives Staff turnover CLC Size CLC % occupancy Urban vs. rural Academic affiliation Demographic Characteristics Comorbidity Baseline Functional Status No No (n=5926) (n=7221) Mean age, years (range) 78.9 (65-106) 78.2 (65-101) 78.7 (65-105) 78.6 (65-101) Male, % Ethnicity, % American Indian Asian/Pacific Islander Black, not Hispanic Hispanic White, not Hispanic Mean Comorbidity Index (range 0-24) Complicated diabetes Chronic lung disease CVD Dementia Myocardial infarction Metastatic tumor PVD Renal disease Depression, % Hemoglobin, %<10 g/dl Sodium %<130 meq/l Creatinine % 1.5 mg/dl No No (n=5926) (n=7221) No No (n=5926) (n=7221) Mean Initial Barthel Score (range 0-90) Mean CPS (range 0-6) Any advanced directive Do not hospitalize Do not resuscitate Living Will Medical POA

4 Medications Prescribed Time to Death in Subjects Matched for Propensity to be Prescribed at baseline. Death Hazard Ratio for duration in months exposure No exposure NonTCA antidepressant Beta Blocker Digoxin Hydralazine Loop diuretic Nitrate NSAID Spironolactone Thiazide diuretic No (n=5926) (n=7221) No Percent Died (%) Study Time (days) Any HF Hospitalization Hazard Ratio for duration in months Conclusions Implications Number of months on an is positively associated with survival and reduced HF hospitalization Improving rates of prescription in this population may reduce mortality and morbidity. 4

5 Outcomes that really matter in this population Next steps measuring what matters And for those who can t self-report? Function Quality of life Function: 6MWT vs. 2MWT Quality of Life KCCQ: 23 items Symptoms, physical & social function, self-efficacy, QoL DCQLS: 1 item Likert scale (5) How have things been going for you during the past 4 weeks? Brief Agitation Rating Scale 10-item caregiver interview Pleasant Events Scale 20 item inventory of pleasant events completed by a caregiver Apparent Affect Rating Scale series of 10-minute observations for verbal expressions, vocalizations and movements indicating whether a subject appears to be experiencing pleasure, anger, anxiety/fear, sadness, interest and contentment Palliative Care End stage Disease Palliative Care 4.9 Eating HELPT predicting 6 month mortality Advance Care Planning 34% of community NH residents have advance directives 74% of VA NH residents have advance directives In VA, absence of an advance directive was associated with terminal hospitalization (Levy et al., 2010) Predicting end of life and hospice eligibility readily available tools that use MDS variables Flacker Porock HELPT (Levy) Cancer Diagnosis 0.8 Supervised 0.2 DNR Order 0.7 Limited Assistance 0.3 Admitted within the last 3 months 0.7 Extensive Assistance 0.7 Leaving >25% of meal uneaten at most meals Total Dependence 0.9 Shortness of Breath 0.5 Mobility/Location Bedfast 0.4 Supervised 0 Oxygen Therapy 0.4 Limited Assistance 0.4 Conditions/diseases that lead to instability 0.4 Extensive Assistance 0.4 BMI >22 kg/m2-0.4 Total Dependence 0.7 Score Sensitivity Specificity PPV NPV <

6 Palliative Care Symptom Management Typical symptoms Breathlessness Fatigue Edema Atypical symptoms Pain Constipation Dry mouth Disease trajectory and prognostic uncertainty Adjusting to functional limitations Adjusting to uncertain prognosis 6