Abstract
Objectives
Studies examining the effects of statins after acute myocardial infarction (AMI) excluded
frail older adults, especially nursing home (NH) residents, and few examined functional
outcomes. Older NH residents may benefit less from statins and be particularly susceptible
to adverse drug events like myopathy-related functional decline. We evaluated the
effects of statins on 1-year functional decline, rehospitalization, and death in NH
residents.
Design
We conducted a retrospective cohort study using 2007-2010 linked national data from
Minimum Data Set (MDS) assessments, Medicare claims, and Online Survey Certification
and Reporting System records.
Setting and Participants
We included US NH residents 65 years and older who were statin nonusers, were hospitalized
for AMI between May 2007 and March 2010, and returned to the NH.
Measures
Outcomes were functional decline, death, and rehospitalization in the first year after
post-AMI NH admission. New statin users were 1:1 propensity-score matched to nonusers
to adjust for 92 characteristics. We estimated hazard ratios (HRs) and restricted
mean survival time differences with 95% confidence intervals (CIs) comparing individuals
who did vs did not initiate statin therapy after AMI hospitalization.
Results
Propensity-score matching yielded a cohort of 5440 residents. Mean age was 83 years
and 69% were female. Statin use was associated with a reduction in mortality (HR 0.80,
95% CI 0.73-0.87), corresponding to a mean of 15.9 (95% CI 9.9-22.0) days of extended
life expectancy. No overall differences in rehospitalization (HR 1.06, 95% CI 0.98-1.14)
or functional decline (HR 1.00, 95% CI 0.88-1.14) were observed.
Conclusions and Implications
Statins may reduce 1-year mortality by 20% without affecting function among older
NH residents who wish to live longer after AMI. During shared decision making with
these patients or their representatives, clinicians should consider communicating
that the average benefit of statins is 16 days of additional survival over 1 year.
Keywords
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References
- AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline from the American Heart Association and American College of Cardiology Foundation.Circulation. 2011; 124: 2458-2473
- 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 61: e78-e140
- 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: e344-e426
- Statins for secondary prevention in elderly patients: A hierarchical Bayesian meta-analysis.J Am Coll Cardiol. 2008; 51: 37-45
- Secondary prevention of atherosclerotic cardiovascular disease in older adults: A scientific statement from the American Heart Association.Circulation. 2013; 128: 2422-2446
- Acute myocardial infarction in nursing home residents: Adherence to treatment guidelines reduces mortality, but why is adherence so low?.J Am Med Dir Assoc. 2009; 10: 56-61
- Secondary prevention medication use after myocardial infarction in U.S. nursing home residents.J Am Geriatr Soc. 2017; 65: 2397-2404
- Beta-blocker use in U.S. nursing home residents after myocardial infarction: A national study.J Am Geriatr Soc. 2017; 65: 754-762
- Medical treatment preferences of nursing home residents: Relationship to function and concordance with surrogate decision-makers.J Am Geriatr Soc. 1993; 41: 953-960
- Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 2013-2014.Vital Health Stat 3. 2016; 38:x-xii: 1-105
- Association of beta-blockers with functional outcomes, death, and rehospitalization in older nursing home residents after acute myocardial infarction.JAMA Intern Med. 2017; 177: 254-262
- Outcomes of “diabetes-friendly” versus “diabetes-unfriendly” beta-blockers in older nursing home residents with diabetes after acute myocardial infarction.Diabetes Obes Metab. 2018; 20: 2724-2732
- Association between secondary prevention medication use and outcomes in frail older adults after acute myocardial infarction.Circ Cardiovasc Qual Outcomes. 2019; 12: e004942
- Designing the national resident assessment instrument for nursing homes.Gerontologist. 1990; 30: 293-307
- Comparing staffing levels in the Online Survey Certification and Reporting (OSCAR) system with the Medicaid Cost Report data: Are differences systematic?.Gerontologist. 2007; 47: 480-489
- Nursing home residents and enrollment in Medicare Part D.J Am Geriatr Soc. 2009; 57: 1902-1907
- The residential history file: Studying nursing home residents' long-term care histories(∗).Health Serv Res. 2011; 46: 120-137
- Scaling ADLs within the MDS.J Gerontol A Biol Sci Med Sci. 1999; 54: M546-M553
- Observational data for comparative effectiveness research: An emulation of randomised trials of statins and primary prevention of coronary heart disease.Stat Method Med Res. 2013; 22: 70-96
- Using big data to emulate a target trial when a randomized trial is not available.Am J Epidemiol. 2016; 183: 758-764
- Comparative effectiveness research using observational data: Active comparators to emulate target trials with inactive comparators.EGEMS (Wash DC). 2016; 4: 1234
- Measuring change in activities of daily living in nursing home residents with moderate to severe cognitive impairment.BMC Geriatr. 2006; 6: 7
- Variations in time to benefit among clinical trials of cholesterol-lowering drugs.J Clin Lipidol. 2018; 12: 857-862
- Prognostic indices for older adults: A systematic review.JAMA. 2012; 307: 182-192
- A comparison of 12 algorithms for matching on the propensity score.Stat Med. 2014; 33: 1057-1069
- Matching methods for causal inference: A review and a look forward.Stat Sci. 2010; 25: 1-21
- The robust inference for the Cox proportional hazards model.J Am Stat Assoc. 1989; 84: 1074-1078
- The use of restricted mean survival time to estimate the treatment effect in randomized clinical trials when the proportional hazards assumption is in doubt.Stat Med. 2011; 30: 2409-2421
- Restricted mean survival time: An alternative to the hazard ratio for the design and analysis of randomized trials with a time-to-event outcome.BMC Med Res Methodol. 2013; 13: 152
- Sensitivity analysis in observational research: Introducing the E-value.Ann Intern Med. 2017; 167: 268-274
- On the distinction between interaction and effect modification.Epidemiology. 2009; 20: 863-871
- Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: Report from the Canadian Study of Health and Aging.J Gerontol A Biol Sci Med Sci. 2004; 59: 1310-1317
- Confidence intervals for the number needed to treat.BMJ. 1998; 317: 1309-1312
- The effect of statins on average survival in randomised trials, an analysis of end point postponement.BMJ Open. 2015; 5: e007118
- Effect of statin (HMG-Co-A-Reductase Inhibitor) use on 1-year mortality and hospitalization rates in older patients with cardiovascular disease living in nursing homes.J Am Geriatr Soc. 2002; 50: 1389-1395
- Increasing levels of restriction in pharmacoepidemiologic database studies of elderly and comparison with randomized trial results.Med Care. 2007; 45: S131-S142
- Pharmacoepidemiology and disability in older adults: Can medications slow the age-related decline in physical function?.Exp Opin Pharmacother. 2004; 5: 407-413
- Associations between statin use and physical function in older adults from the Netherlands and Australia: Longitudinal Aging Study Amsterdam and Australian Longitudinal Study on Women's Health.Drugs Aging. 2016; 33: 437-445
- Angiotensin-converting enzyme inhibitor and statin use and incident mobility limitation in community-dwelling older adults: The Health, Aging and Body Composition Study.J Am Geriatr Soc. 2011; 59: 2226-2232
- Guideline-recommended medications and physical function in older adults with multiple chronic conditions.J Am Geriatr Soc. 2017; 65: 2619-2626
- 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2019; 73: 3168-3209
- A structural approach to selection bias.Epidemiology. 2004; 15: 615-625
- Comparison of treatment effects measured by the hazard ratio and by the ratio of restricted mean survival times in oncology randomized controlled trials.J Clin Oncol. 2016; 34: 1813-1819
References
- Association of beta-blockers with functional outcomes, death, and rehospitalization in older nursing home residents after acute myocardial infarction.JAMA Intern Med. 2017; 177: 254-262
- Secondary prevention medication use after myocardial infarction in U.S. nursing home residents.J Am Geriatr Soc. 2017; 65: 2397-2404
- Beta-blocker use in U.S. nursing home residents after myocardial infarction: A national study.J Am Geriatr Soc. 2017; 65: 754-762
- Comparison of the Elixhauser and Charlson/Deyo methods of comorbidity measurement in administrative data.Med Care. 2004; 42: 355-360
- Measuring change in activities of daily living in nursing home residents with moderate to severe cognitive impairment.BMC Geriatr. 2006; 6: 7
- MDS Cognitive Performance Scale.J Gerontol. 1994; 49: M174-M182
- A comprehensive clinical assessment tool to inform policy and practice: applications of the Minimum Data Set.Med Care. 2004; 42: III50-III59
- Scaling ADLs within the MDS.J Gerontol A Biol Sci Med Sci. 1999; 54: M546-M553
Article info
Publication history
Published online: March 03, 2020
Footnotes
This study was supported by grants R01HL111032 and K24AG049057 from the National Institutes of Health (NIH), and by awards 5K12HS022998 from the Agency for Healthcare Research and Quality, R21AG061632 from the National Institute on Aging, and U54GM115677 from the National Institute of General Medical Sciences to ARZ. In addition, ARZ is supported by a US Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship in Health Services Research and Development. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
The authors declare no conflicts of interest.
Identification
Copyright
Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.
