Editor's Note: Commentary based on Mack DS, Tjia J, Hume AL, Lapane KL. Prevalent statin use in long-stay nursing home residents with life-limiting illness. J Am Geriatr Soc 2020;68:708-16.²

Geriatric Cardiology Perspective Points:

• There is limited appreciation of cardiovascular care delivered in long-term skilled nursing facilities by cardiovascular clinicians.
• Residents of long-term skilled nursing facilities – often with life-limiting illnesses – are not included in cardiovascular clinical trials.
• Current US guidelines addressing statin use in older adults residing in skilled nursing facilities are inconsistent and controversial.
• There is a high prevalence of polypharmacy (≥5 medications) and hyper-polypharmacy (≥10 medications) among nursing home residents despite having life-limiting illness² with statin use highly correlated with concurrent non-statin medication use.
• The Centers for Medicare & Medicaid Services has stated that the presence of ≥9 medications is an indicator of poor nursing home quality of care.²
• Balancing medication burden with the perceived benefits of specific pharmaceutical agents such as statins in non-community dwelling patients with limited life expectancy is critical.
• Optimal care and decision-making for older, multimorbid adults should therefore:
  • Include consideration of life expectancy⁴
  • Incorporate (if present) statistical tools that can aid in shared decision making [such as restricted mean survival time^5-7] and concepts of time to benefit and time to harm.^8,9
• Finally, deprescribing of cardiovascular medications should take into account:
  • Specific triggers (polypharmacy, adverse events [current or future], prescribing cascades, limited life expectancy).
  • A framework that includes multiple domains (addressing physical, cognitive, medical/surgical, social, and what matters most).^10,11
  • A supervised methodical deprescribing process.³

Rationale for study:  Evaluate prevalence of statin use in long-stay nursing home residents with life-limiting illness and estimate factors associated with statin pharmacotherapy.²

Funding: National Center for Advancing Translational Sciences, National Institutes of Health (TL1 TR001454), and the Agency for Healthcare Research and Quality (R36HS026840).

Study Cohort:  Long-stay nursing home residents near the end of life who resided in a Medicare and Medicaid-certified nursing home facility on a target date, September 30, 2016.

Inclusion criteria:

1. Current nursing home resident.
2. Long-stay resident (≥90 days).
3. Age 65 years or older.
4. Continuous coverage of Medicare fee-for-service part A, B, and D in the three months before study entry.
5. Strictly defined and previously validated claims data-based definition of limited life expectancy (<6 months) or diagnosed with a life-limiting illness.

Exclusion criteria: Hospice enrollment.

Study Design: Cross-sectional study. Use of Minimum Data Set (MDS) 3.0, a federally mandated nursing home assessment data linked to Medicare claims data (Part A, Part D, and Medicare Beneficiary Summary File).

Outcomes: Prevalence of statins prescription and factors that associated with statins prescription.

Statistical Analysis
Descriptive statistics were used for residents' baseline characteristics. The point prevalence of statin use (yes/no) was estimated as of the target date. Poisson models with facility clustering, an exchangeable correlation matrix, and robust confidence intervals (CI) were used to estimate crude and adjusted prevalence ratios and 95% CIs of statin use by resident variables. All analyses were stratified by age group.

Results
Overview of the cohort:

• Long-stay nursing home residents with life-limiting illness were included (N = 424,212).
• 99.1% were diagnosed with at least one "serious illness", 16.1% had a condition that met the criteria in the Palliative Care Index (PCI), 3.1% had a documented prognosis less than 6 months, and less than 1% had evidence of recent palliative consult.

Total statin use and by age:

• Overall prevalence of statin use among those with life-limiting illness was 34% (44.0% in 65-75 years old and 31.1% in >75 years old).
• In the cohort of 65-75 years old: 
  • 23.0% of those with prognosis ˂6 months of life expectance, 16.0% of those who received palliative care consult, 40.1% of those who had PCI, and 44.2% of those who were identified to have "serious illness" were prescribed with statins.
• In the cohort of >75 years old:
  • 12.2% of those with prognosis <6 months, 8.7% of those who received palliative care consult, 31.7% of those with PCI, and 29.5% of those with "serious illness" were prescribed with statins.

Limitations:
Cohort limited to Medicare fee-for-service beneficiaries.
Actual medical utilization was not possible due to retrospective study design.

References

1. Kutner JS, Blatchford PJ, Taylor DH, Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med 2015;175:691-700.
2. Mack DS, Tjia J, Hume AL, Lapane KL. Prevalent statin use in long-stay nursing home residents with life-limiting illness. J Am Geriatr Soc 2020;68:708-16.
3. Krishnaswami A, Steinman MA, Goyal P, et al. Deprescribing in older adults with cardiovascular disease. J Am Coll Cardiol 2019;73:2584-95.
4. Boyd C, Smith CD, Masoudi FA, et al. Framework for decision-making for older adults with multiple chronic conditions: executive summary for the American Geriatrics Society Guiding Principles on the Care of Older Adults With Multimorbidity. J Am Geriatr Soc 2019;67:665-73.
5. Krishnaswami A, Peterson ED, Kim DH, Goyal P, Rich MW. Efficacy and safety of intensive blood pressure therapy using restricted mean survival time - insights from the SPRINT trial. Am J Med 2020;133:e369-70.
6. McCaw ZR, Orkaby AR, Wei LJ, Kim DH, Rich MW. Applying evidence-based medicine to shared decision making: value of restricted meansurvival time. Am J Med 2019;132:13-15.
7. Kim DH, Uno H, Wei LJ. Restricted mean survival time as a measure to interpret clinical trial results. JAMA Cardiol 2017;2:1179-80.
8. Lee SJ, Kim CM. Individualizing prevention for older adults. J Am Geriatr Soc 2018;66:229-34.
9. Lee SJ, Leipzig RM, Walter LC. Incorporating lag time to benefit into prevention decisions for older adults. JAMA 2013;310:2609-10.
10. Gorodeski EZ, Goyal P, Hummel SL, et al. Domain management approach to heart failure in the geriatric patient: present and future. J Am Coll Cardiol 2018;71:1921-36.
11. Tinetti M, Huang A, Molnar F. The geriatrics 5M's: a new way of communicating what we do. J Am Geriatr Soc 2017;65:2115.

Clinical Topics: Dyslipidemia, Geriatric Cardiology, Nonstatins, Novel Agents, Statins

Keywords: Geriatrics, Medicare, Fee-for-Service Plans, Cross-Sectional Studies, Hospices, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Medicaid, Retrospective Studies, Skilled Nursing Facilities, Palliative Care, Prevalence, Confidence Intervals, Life Expectancy

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