Secondary Prevention Medication Use After Myocardial Infarction in U.S. Nursing Home Residents.

Zullo AR, Sharmin S, Lee Y, Daiello LA, Shah NR, John Boscardin W, Dore DD, Lee SJ, Steinman MA. Secondary Prevention Medication Use After Myocardial Infarction in U.S. Nursing Home Residents. Journal of the American Geriatrics Society. 2017 Nov 1; 65(11):2397-2404.

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Abstract:

BACKGROUND/OBJECTIVES: Secondary prevention medications are recommended for older adults after acute myocardial infarction (AMI), but little is known about whether nursing home (NH) residents receive these medications. The objective was to evaluate new use of secondary prevention medications after AMI in NH residents who were previously nonusers and to evaluate what factors were associated with use. DESIGN: Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. SETTING: U.S. NHs. PARTICIPANTS: National cohort of 11,192 NH residents aged 65 and older who were hospitalized for an AMI between May 2007 and March 2010, had no beta-blocker or statin use for 4 months or longer before the hospitalization, and survived 14 days or more after NH readmission. MEASUREMENTS: The outcome was the number of secondary prevention medications initiated within 30 days of NH readmission. RESULTS: Thirty-seven percent of residents had no secondary prevention medications initiated after AMI, 41% had 1 initiated, and 22% had 2 initiated. After covariate adjustment, fewer secondary prevention medications were used in older residents (proportional odds ratio (POR)  =  0.48, 95% confidence interval (CI)   =  0.40-0.57 for = 95 vs 65-74); women (POR  =  0.88, 95% CI  =  0.80-0.96);and those with a do-not-resuscitate (DNR) order (POR  =  0.90, 95% CI  =  0.83-0.98), functional impairment (dependent or totally dependent vs independent to limited assistance, POR  =  0.77, 95% CI  =  0.69-0.86), and cognitive impairment (moderate to severe vs no impairment, POR  =  0.79, 95% CI  =  0.70-0.89). CONCLUSION: More than one-third of older NH residents in the United States do not have any secondary prevention medications initiated after AMI, with fewer medications initiated in older residents; women; and those with, DNR orders, poor physical function, and cognitive impairment. A lack of evidence about the safety and effectiveness of secondary preventions medications in the NH population and unmeasured person-centered goals of care are plausible explanations for these findings.