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IIR 14-306 – HSR Study

IIR 14-306
De-Intensifying Unnecessary Medications in VA CLC Residents Nearing End of Life
Carolyn T. Thorpe, PhD MPH
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: May 2016 - June 2021
Each year, VA cares for thousands of Veterans in VA nursing homes, known as Community Living Centers (CLCs). The CLC is a key setting for the delivery of end-of-life (EOL) care, and encouraging appropriate palliative care, avoiding burdensome interventions, and supporting treatment decisions that maximize quality of life are major priorities. An aspect of palliative care that has tremendous potential to positively impact VA CLC residents with limited life expectancy and/or advanced dementia (LLE/AD) is the de-intensification of chronic disease medications that have reduced benefits and increased risks and burdens in the context of LLE/AD. In the years leading up to the development of AD and other life-limiting conditions, most CLC residents have accumulated multiple chronic conditions requiring medication therapy (e.g., coronary artery disease, hypertension, diabetes). However, practice guidelines developed for general populations calling for intense treatment of these conditions may no longer be appropriate for residents with LLE/AD, given their reduced potential to live long enough to experience benefits and higher propensity for adverse drug reactions. Several groups have issued recommendations for intense chronic disease treatments to avoid in patients with LLE/AD, but their adoption in CLC practice, and actual benefits and risks to patients associated with their implementation, is unknown.

Specific aims are to: (1) describe patterns of receipt of intense vs. de-intensified treatment for lipid, blood pressure (BP), and glycemic control in Veterans with LLE/AD after CLC admission; (2) examine effects of intense treatment for lipid, BP, and glycemic control after CLC admission on all-cause negative events and disease-specific hospitalizations and emergency visits in Veterans with LLE/AD; and (3) identify key barriers and facilitators to implementing LLE/AD-specific recommendations and design an intervention toolkit to serve as the basis for quality improvement (QI) efforts.

This is a mixed-methods study with two phases. For quantitative aims 1-2, we will link Minimum Dataset (MDS) assessments, medication records, VA utilization/clinical data, and Medicare claims to examine variation across CLCs in intense vs. de-intensified treatment; and determine effects on all-cause and disease-specific negative events. Our analytic approach uses propensity score methods with inverse probability of treatment weights to minimize selection bias and confounding. Using results from Aim 1 to purposively sample from CLCs with lower proportions of intensely treated residents ("early adopters" of LLE/AD recommendations) and higher proportions of intensely treated residents ("late adopters"), qualitative Aim 3 will involve semi-structured interviews with providers and family caregivers of recently deceased CLC residents. With input from VA clinical and operational partners, we will use these data to map key barriers and facilitators to implementing LLE/AD-specific recommendations and develop an intervention toolkit that will serve as a basis for future QI efforts.

We have obtained and linked data for quantitative aims 1-2. We have validated our approach for using the MDS to identify patients with LLE, and identified a sample of 58,908 CLC episodes in FY2009-2015 lasting at least 7 days for Veterans aged 65 years of age who have evidence of LLE/AD at admission. Preliminary analyses of the subsample with coronary artery disease, history of stroke/transient ischemic attack, and/or diabetes (n=44,041) reveal that 36% of these Veterans receive intense treatment for lipid control; i.e., they are treated with statins at CLC admission. Approximately 21% of patients initially treated with statins at admission subsequently discontinue statin use within 90 days.

This study addresses the HSR&D Priority Area on Long-Term Care and Caregiving and Strategies 1-3 of the VA Blueprint for Excellence. It will have significant impact by providing VA with critical information and tools needed to improve quality and safety of prescribing and shared decision-making in CLC residents near end-of-life.

External Links for this Project

NIH Reporter

Grant Number: I01HX001759-01A2

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Journal Articles

  1. Niznik JD, Zhang S, Mor MK, Zhao X, Ersek M, Aspinall SL, Gellad WF, Thorpe JM, Hanlon JT, Schleiden LJ, Springer S, Thorpe CT. Adaptation and Initial Validation of Minimum Data Set (MDS) Mortality Risk Index to MDS Version 3.0. Journal of the American Geriatrics Society. 2018 Dec 1; 66(12):2353-2359. [view]
  2. Vu M, Sileanu FE, Aspinall SL, Niznik JD, Springer SP, Mor MK, Zhao X, Ersek M, Hanlon JT, Gellad WF, Schleiden LJ, Thorpe JM, Thorpe CT. Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes. Journal of The American Medical Directors Association. 2021 Jan 1; 22(1):132-140.e5. [view]
  3. Aspinall SL, Springer SP, Zhao X, Cunningham FE, Thorpe CT, Semla TP, Shorr RI, Hanlon JT. Central Nervous System Medication Burden and Risk of Recurrent Serious Falls and Hip Fractures in Veterans Affairs Nursing Home Residents. Journal of the American Geriatrics Society. 2019 Jan 1; 67(1):74-80. [view]
  4. Niznik JD, Hunnicutt JN, Zhao X, Mor MK, Sileanu F, Aspinall SL, Springer SP, Ersek MJ, Gellad WF, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes. Journal of the American Geriatrics Society. 2020 Apr 1; 68(4):736-745. [view]
  5. Alexopoulos AS, Kahkoska AR, Pate V, Bradley MC, Niznik J, Thorpe C, Stürmer T, Buse J. Deintensification of Treatment With Sulfonylurea and Insulin After Severe Hypoglycemia Among Older Adults With Diabetes. JAMA Network Open. 2021 Nov 1; 4(11):e2132215. [view]
  6. Aspinall SL, Hanlon JT, Niznik JD, Springer SP, Thorpe CT. Deprescribing in Older Nursing Home Patients: Focus on Innovative Composite Measures for Dosage Deintensification. Innovation in aging. 2017 Sep 1; 1(2):igx031. [view]
  7. Thorpe CT, Sileanu FE, Mor MK, Zhao X, Aspinall S, Ersek M, Springer S, Niznik JD, Vu M, Schleiden LJ, Gellad WF, Hunnicutt J, Thorpe JM, Hanlon JT. Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life. Journal of the American Geriatrics Society. 2020 Nov 1; 68(11):2609-2619. [view]
  8. Niznik JD, Zhao X, Slieanu F, Mor MK, Aspinall SL, Gellad WF, Ersek M, Hickson RP, Springer SP, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Effect of Deintensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents. Diabetes Care. 2022 Jul 7; 45(7):1558-1567. [view]
  9. Vu M, Schleiden LJ, Harlan ML, Thorpe CT. Hypertension Management in Nursing Homes: Review of Evidence and Considerations for Care. Current Hypertension Reports. 2020 Jan 14; 22(1):8. [view]
  10. Springer SP, Mor MK, Sileanu F, Zhao X, Aspinall SL, Ersek M, Niznik JD, Hanlon JT, Hunnicutt J, Gellad WF, Schleiden LJ, Thorpe JM, Thorpe CT. Incidence and Predictors of Aspirin Discontinuation in Older Adult Veteran Nursing Home Residents at End of Life. Journal of the American Geriatrics Society. 2020 Apr 1; 68(4):725-735. [view]
  11. Radomski TR, Zhao X, Hanlon JT, Thorpe JM, Thorpe CT, Naples JG, Sileanu FE, Cashy JP, Hale JA, Mor MK, Hausmann LRM, Donohue JM, Suda KJ, Stroupe KT, Good CB, Fine MJ, Gellad WF. Use of a medication-based risk adjustment index to predict mortality among veterans dually-enrolled in VA and medicare. Healthcare (Amsterdam, Netherlands). 2019 Dec 1; 7(4). [view]

DRA: Aging, Older Veterans' Health and Care
DRE: TRL - Applied/Translational
Keywords: Best Practices, Cardiovascular Disease, Decision-Making, Dementia, Diabetes, End-of-Life, Medication Management, Outcomes - Patient, Practice Patterns/Trends
MeSH Terms: none

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