Sydney P Springer1,2,3, Maria K Mor1,4, Florentina Sileanu1, Xinhua Zhao1,4, Sherrie L Aspinall1,5, Mary Ersek6,7, Joshua D Niznik8, Joseph T Hanlon1,4, Jacob Hunnicutt1,9, Walid F Gellad1,3, Loren J Schleiden1,2, Joshua M Thorpe1,10, Carolyn T Thorpe1,10. 1. VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania. 2. Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania. 3. University of New England College of Pharmacy, Department of Pharmacy Practice, Portland, ME. 4. University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA. 5. Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania. 6. Corporal Michael J. Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA. 7. University of Pennsylvania School of Nursing, Department of Biobehavioral Health Sciences, Philadelphia, PA. 8. University of North Carolina School of Medicine, Division of Geriatric Medicine, Chapel Hill, NC. 9. Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. 10. University of North Carolina Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Chapel Hill, NC.
Abstract
OBJECTIVES: Continuation of aspirin for secondary prevention in persons with limited life expectancy (LLE) is controversial. We sought to determine the incidence and predictors of aspirin discontinuation in veterans with LLE and/or advanced dementia (LLE/AD) who were taking aspirin for secondary prevention at nursing home admission, stratified by whether their limited prognosis (LP) was explicitly documented at admission. DESIGN: Retrospective cohort study using linked Veterans Affairs (VA) and Medicare clinical/administrative data and Minimum Data Set resident assessments. SETTING: All VA nursing homes (referred to as community living centers [CLCs]) in the United States. PARTICIPANTS: Older (≥65 y) CLC residents with LLE/AD, admitted for 7 days or longer in fiscal years 2009 to 2015, who had a history of coronary artery disease and/or stroke/transient ischemic attack, and used aspirin within the first week of CLC admission (n = 13 844). MEASUREMENTS: The primary dependent variable was aspirin discontinuation within the first 90 days after CLC admission, defined as 14 consecutive days of no aspirin receipt. Independent variables included an indicator for explicit documentation of LP, sociodemographics, environment of care characteristics, cardiovascular risk factors, bleeding risk factors, individual markers of poor prognosis (eg, cancer, weight loss), and facility characteristics. Fine and Gray subdistribution hazard models with death as a competing risk were used to assess predictors of discontinuation. RESULTS: Cumulative incidence of aspirin discontinuation was 27% (95% confidence interval [CI] = 26%-28%) in the full sample, 34% (95% CI = 33%-36%) in residents with explicit documentation of LP, and 24% (95% CI = 23%-25%) in residents with no such documentation. The associations of independent variables with aspirin discontinuation differed in residents with vs without explicit LP documentation at admission. CONCLUSION: Just over one-quarter of patients discontinued aspirin, possibly reflecting the unclear role of aspirin in end of life among prescribers. Future research should compare outcomes of aspirin deprescribing in this population. J Am Geriatr Soc 68:725-735, 2020. Published 2020. This article is a U.S. Government work and is in the public domain in the USA.
OBJECTIVES: Continuation of aspirin for secondary prevention in persons with limited life expectancy (LLE) is controversial. We sought to determine the incidence and predictors of aspirin discontinuation in veterans with LLE and/or advanced dementia (LLE/AD) who were taking aspirin for secondary prevention at nursing home admission, stratified by whether their limited prognosis (LP) was explicitly documented at admission. DESIGN: Retrospective cohort study using linked Veterans Affairs (VA) and Medicare clinical/administrative data and Minimum Data Set resident assessments. SETTING: All VA nursing homes (referred to as community living centers [CLCs]) in the United States. PARTICIPANTS: Older (≥65 y) CLC residents with LLE/AD, admitted for 7 days or longer in fiscal years 2009 to 2015, who had a history of coronary artery disease and/or stroke/transient ischemic attack, and used aspirin within the first week of CLC admission (n = 13 844). MEASUREMENTS: The primary dependent variable was aspirin discontinuation within the first 90 days after CLC admission, defined as 14 consecutive days of no aspirin receipt. Independent variables included an indicator for explicit documentation of LP, sociodemographics, environment of care characteristics, cardiovascular risk factors, bleeding risk factors, individual markers of poor prognosis (eg, cancer, weight loss), and facility characteristics. Fine and Gray subdistribution hazard models with death as a competing risk were used to assess predictors of discontinuation. RESULTS: Cumulative incidence of aspirin discontinuation was 27% (95% confidence interval [CI] = 26%-28%) in the full sample, 34% (95% CI = 33%-36%) in residents with explicit documentation of LP, and 24% (95% CI = 23%-25%) in residents with no such documentation. The associations of independent variables with aspirin discontinuation differed in residents with vs without explicit LP documentation at admission. CONCLUSION: Just over one-quarter of patients discontinued aspirin, possibly reflecting the unclear role of aspirin in end of life among prescribers. Future research should compare outcomes of aspirin deprescribing in this population. J Am Geriatr Soc 68:725-735, 2020. Published 2020. This article is a U.S. Government work and is in the public domain in the USA.
Entities:
Keywords:
chronic disease management; deprescribing; end of life; epidemiology; veterans
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