Background/objectives
The extent to which individual knowledge, preferences, and priorities explain lower use of invasive cardiac care among older vs. younger adults presenting with acute coronary syndrome (ACS) is unknown. We directly surveyed a group of patients to ascertain their preferences and priorities for invasive cardiovascular care.
Design
We performed a prospective cohort study of adults hospitalized with ACS. We surveyed participants regarding their knowledge, preferences, goals, and concerns for cardiac care, as well as their risk tolerance for coronary artery bypass grafting (CABG).
Setting
Single academic medical center.
Participants
Six hundred twenty-eight participants (373 <75 years old; 255 ≥75 years old).
Measurements
We compared baseline characteristics, knowledge, priorities, and risk tolerance for care across age strata. We also assessed pairwise differences with 95% confidence intervals (CI) between age groups for key variables of interest.
Results
Compared with younger patients, older participants had less knowledge of invasive care; were less willing to consider cardiac catheterization (difference between 75–84 and< 65 years old: −7.8%, 95% CI: −14.4%,-1.3%; for ≥85 vs. <65: −15.7%, 95% CI: −29.8%,-1.6%), percutaneous coronary intervention (difference between 75–84 and< 65 years old: −12.8%, 95% CI: −20.8%,-4.8%; for ≥85 vs. <65: −24.8%, 95% CI: −41.2%,-8.5%), and CABG (difference between 75–84 and< 65 years old: −19.0%, 95% CI: −28.2%,-9.9%; for ≥85 vs. <65: −39.1%, 95% CI: −56.0%,-22.2%); and were more risk averse for CABG surgery (p < .001), albeit with substantial inter-individual variability and individual outliers. Many patients who stated they were not initially willing to undergo an invasive cardiovascular procedure actually ended up undergoing the procedure (49% for cardiac catheterization and 22% for PCI or CABG).
Conclusion
Age influences treatment goals and willingness to consider invasive cardiac care, as well as risk tolerance for CABG. Individuals’ willingness to undergo invasive cardiovascular procedures loosely corresponds with whether that procedure is performed after discussion with the care team.
High quality evidence supports survival, quality of life, and functional status benefits from revascularization in patients with acute coronary syndrome (ACS), but older adults remain less likely than younger adults to be treated with an invasive strategy. Major efforts to improve awareness and close gaps in care for older adults with ACS have been successful. Even with substantial progress, gaps in evidence-based invasive care persist, including differential use of coronary angiography and revascularization. Guidelines encourage an individualized approach to evidence-based care for older adults, given limited representation in the evidence particularly for patients with advanced age, multiple chronic conditions, or frailty. Data to inform the care of this complex population are lacking, making decisions more nuanced and magnifying the importance of incorporating individual patient preferences into shared decision-making.
Despite the important role of individual preferences for care, there has been no systematic study of the knowledge, beliefs, and preferences among older patients prior to invasive cardiovascular procedures and how age influences these preferences. Also, a quantitative assessment of risk tolerance for invasive care has not been published. Additionally, the relationship between the priorities and concerns a patient brings to a decision and actual treatment remains unclear. As a result, we sought to systematically investigate whether older adults consider risks and benefits of invasive procedures differently than younger adults. Specifically, we set out to examine the role age plays in the: 1) knowledge, preferences, goals, and concerns for cardiac care; 2) risk tolerance for coronary artery bypass grafting (CABG) surgery; and 3) whether willingness to consider catheterization, percutaneous coronary intervention (PCI), or CABG, corresponds with actual utilization of the procedure.
Methods
We performed a single-center study to directly ascertain the patient-reported preferences, goals and concerns around decisions to undergo invasive cardiovascular care which provide the context for decision-making in older adults. We prospectively surveyed 628 participants (373 age <75 years, and 255 age ≥75 years) admitted to Duke University Medical Center from August 2000 to July 2001 on their priorities and risk tolerance for cardiac care. Inclusion criteria were >45 years of age admitted for ACS, defined as chest pain with either positive cardiac enzymes, stress test, or electrocardiogram changes. All patients were stable patients on the wards; patients with STEMI were excluded. Exclusion criteria were prior CABG or PCI within the preceding 6 months, cardiac catheterization within the preceding 3 months, primary congenital or valvular heart disease, dementia, terminal illness with prognosis of less than 1 year, or inability to provide informed consent. Informed consent was obtained in all patients prior to the survey administration. The Duke Institutional Review Board approved this study.
We abstracted baseline demographics and clinical characteristics from chart review and interviewed all participants prior to discussion of treatment and possible cardiac catheterization to ascertain their knowledge. This was done by two study coordinators using a survey and standard gamble instrument. This study’s coordinators followed a script to ensure consistency in approaching participants. The survey included assessments of quality of life, as well as prior knowledge and willingness to consider invasive care (cardiac catheterization, PCI, or CABG) if recommended by their clinician. Knowledge of cardiac catheterization, PCI, or CABG, respectively, was defined as responding “Yes” to any of the following: 1) having had that procedure previously; 2) having a family member, friend, or acquaintance who underwent that procedure; or 3) having received information or a description of that procedure during their hospital stay. Willingness to consider cardiac catheterization, PCI, or CABG, respectively, was defined as responding “Definitely Yes” or “Probably Yes” to the question of whether they would consider those procedures if their doctor recommended them. General health status was assessed using the Short Form 36 Health Survey (SF-36) instrument. The SF-36 provides a physical and mental component summary score using a norm-based scoring system standardized to a mean (standard deviation) of 50 (10), with higher scores indicating better health status. We asked participants about the role of age in treatment decisions, and to rank their top three goals (choosing from: lengthen life, relieve symptoms, maintain independence, maintain mental acuity, and prevent heart attack), as well as their top three concerns for care (choosing from: loss of independence, burden on others, cost of care, long hospital stay, loss of physical strength/ability, loss of mental capacity, and dying). Responses were summarized in heat maps to represent commonly selected goals or concerns across age groups. We counted participants willing to consider CABG if they responded “Definitely Yes” or “Probably Yes” to the question, “If your doctor recommended that you have CABG surgery to improve the blood flow to your heart, would you consider doing so?” We asked participants to state their preference if they had to choose between quality and quantity of life. We asked if age should be an important component in their treatment decisions and if there was an age at which they would decline CABG surgery. Participants also answered questions about how religious (scale 1-4), optimistic (scale 1-5), and satisfied with life they are.
We used a standard gamble to assess risk tolerance for CABG surgery. The standard gamble is a hypothetical scenario comparing treatment with medical therapy or CABG surgery, which has a varying risk of operative mortality (Supplementary Material). Participants were asked to choose between medical therapy and CABG surgery in scenarios where operative mortality associated with CABG surgery changed, alternating from high (e.g., 90%) to low (e.g., 2%), from each extreme progressing towards the middle. The highest risk prior to the participant changing preference away from CABG is their tolerated risk of CABG mortality. Laminated pie chart illustrations supported the standard gamble assessment that was also performed by a single coordinator. We collected catheterization, revascularization, and survival through 30 days of baseline assessment.
All baseline characteristics and survey responses are stratified by four age groups (<65, 65-74, 75-84, and ≥85 years). Categorical variables are shown as percentages and tested with chi-square tests. Continuous variables are shown as medians and interquartile ranges and tested with Kruskal-Wallis tests. We evaluated the association between willingness to consider catheterization, PCI, CABG, or revascularization (PCI or CABG), as well as the respective procedural outcomes, using chi-square tests. In addition, we assessed pairwise differences in frequencies for categorical variables and least squared means for continuous variables with corresponding 95% confidence intervals (CIs) between older age groups (65-74, 75-84, and ≥85 years old) compared with the <65 group. Specifically, we assessed pairwise differences for physical component score, knowledge of cardiac catheterization, PCI, & CABG, willingness to consider cardiac catheterization, PCI & CABG, age as an important consideration in decisions, and the age beyond which you would refuse CABG. A test of linear trend in standard gamble scores was performed across age groups (<65, 65-74, 75-84, ≥85). Finally, we reported rates of cardiac catheterization, PCI, CABG, and all-cause mortality within 30 days by age group. We used logistic regression to test the association between age (per 10-year increase) and invasive care, reporting ORs with 95% CIs.
For all comparisons, we used two-sided tests at a nominal significance level of 0.05. All statistical analyses were performed using SAS version 9.4 (SAS Institute, Inc., Cary, NC).
Results
Baseline characteristics
Sex, race, education, income, diabetes, peripheral vascular disease, and history of CABG and myocardial infarction differed across age groups ( Table I ). Older participants were frequently retired or widowed, while younger participants were frequently married, smokers, or had hyperlipidemia. Quality of life measures differed between the four groups with lower physical function scores in the oldest old (≥85) compared with the <65 group ( Table I ; difference between ≥85 and< 65: −14.5, 95% CI: −27.6,-1.4). All ages reported high levels of optimism, religiosity, and life satisfaction.
| Age Group | |||||
|---|---|---|---|---|---|
| Characteristic | <65 (N = 209) | 65-74 (N = 164) | 75-84 (N = 215) | ≥85 (N = 40) | P |
| Age, median (IQR), years | 56 (51-60) | 71 (68-73) | 79 (77-81) | 87 (86-90) | |
| Male | 123 (58.9%) | 95 (57.9%) | 97 (45.1%) | 23 (57.5%) | .018 |
| Race | <.001 | ||||
| White/Caucasian | 112 (57.7%) | 116 (77.3%) | 153 (76.1%) | 28 (71.8%) | |
| African American | 59 (30.4%) | 28 (18.7%) | 31 (15.4%) | 10 (25.6%) | |
| Other | 23 (11.9%) | 6 (4.0%) | 17 (8.5%) | 1 (2.6%) | |
| Marital status | <.001 | ||||
| Married | 117 (65.4%) | 90 (62.5%) | 95 (50.0%) | 11 (29.7%) | |
| Widowed | 15 (8.4%) | 36 (25.0%) | 81 (42.6%) | 25 (67.6%) | |
| Divorced/separated/never married | 47 (26.3%) | 18 (12.5%) | 14 (7.4%) | 1 (2.7%) | |
| Education | 0.002 | ||||
| Eighth grade or less/some high school | 48 (26.8%) | 51 (35.2%) | 74 (40.0%) | 13 (36.1%) | |
| High school/GED/technical school/some college | 103 (57.5%) | 69 (47.6%) | 70 (37.8%) | 11 (30.6%) | |
| College graduate/professional degree | 28 (15.6%) | 25 (17.2%) | 41 (22.2%) | 12 (33.3%) | |
| Income | 0.027 | ||||
| $0-$19,999 | 61 (38.6%) | 55 (47.4%) | 88 (57.9%) | 13 (46.4%) | |
| $20.000-59,999 | 58 (36.7%) | 43 (37.1%) | 40 (26.3%) | 11 (39.3%) | |
| $60,000 or greater | 39 (24.7%) | 18 (15.5%) | 24 (15.8%) | 4 (14.3%) | |
| Retired | 77 (43.3%) | 124 (85.5%) | 171 (90.5%) | 35 (94.6%) | <.001 |
| Diabetes | 59 (28.2%) | 60 (37.5%) | 60 (27.9%) | 5 (12.5%) | 0.012 |
| Hypertension | 134 (64.1%) | 116 (72.0%) | 157 (73.0%) | 26 (65.0%) | 0.175 |
| Smoking | 117 (56.0%) | 72 (44.7%) | 68 (31.8%) | 12 (30.0%) | <.001 |
| Hyperlipidemia | 116 (55.5%) | 100 (62.1%) | 93 (43.5%) | 15 (38.5%) | <.001 |
| Heart failure | 31 (14.8%) | 17 (10.6%) | 43 (20.0%) | 9 (22.5%) | 0.056 |
| COPD | 25 (12.0%) | 28 (17.4%) | 29 (13.5%) | 8 (20.0%) | 0.342 |
| PVD | 28 (13.4%) | 36 (22.4%) | 59 (27.4%) | 7 (17.5%) | 0.004 |
| Prior cardiac catheterization | 56 (26.8%) | 50 (31.1%) | 72 (33.5%) | 12 (30.0%) | 0.515 |
| Prior MI | 64 (30.6%) | 72 (44.7%) | 88 (40.9%) | 20 (50.0%) | 0.013 |
| Prior PCI | 35 (16.7%) | 37 (23.0%) | 34 (15.8%) | 3 (7.5%) | 0.084 |
| Prior CABG | 28 (13.4%) | 54 (33.5%) | 63 (29.3%) | 5 (12.5%) | <.001 |
| Baseline health status and perspectives | |||||
| General health (SF-36), median (IQR) | 47 (30-62) | 45 (30-62) | 50 (35-70) | 51 (35-70) | 0.400 |
| Physical component score (SF-36), median (IQR) | 55 (35-85) | 50 (25-80) | 45 (25-70) | 40 (20-55) | 0.028 |
| Mental component score (SF-36), median (IQR) | 68 (48-80) | 72 (56-84) | 72 (52-84) | 74 (60-84) | 0.015 |
| Health utility (1-100), median (IQR) | 70 (50-80) | 70 (50-80) | 60 (50-75) | 60 (50-75) | 0.402 |
| Life satisfaction (1-15), median (IQR) | 9 (6-11) | 10 (8-12) | 9 (7-11) | 9 (7-12) | 0.205 |
| Optimism (O, VO) | 131 (80.4%) | 111 (86.0%) | 138 (81.2%) | 29 (85.3%) | 0.568 |
| Religious (R, VR) | 147 (84.5%) | 126 (90.6%) | 171 (94.5%) | 31 (86.1%) | 0.017 |
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