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Patient Cognitive Status and Physician Recommendations for Cardiovascular Disease Treatment: Results of Two
Deborah A Levine1,2,3,4, Rachael T Whitney5, Andrzej T Galecki5,6
1Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, USA. deblevin@umich.edu.
Insights
Physicians recommended guideline-concordant cardiovascular treatments for patients with mild cognitive impairment (MCI) similarly to those with normal cognition (NC). However, fewer treatments were recommended for patients with early-stage dementia compared to NC patients.
Area of Science:
- Cardiology
- Neurology
- Geriatrics
- Health Services Research
Background:
- Clinical guidelines advocate for consistent cardiovascular disease (CVD) care for older adults (65+) with mild cognitive impairment (MCI) and early-stage dementia, matching that of normal cognition (NC) patients.
- Evidence indicates that older adults with MCI and dementia receive suboptimal care for CVD and other conditions compared to their NC counterparts.
- The impact of cognitive status on physician treatment recommendations following acute myocardial infarction (AMI) and acute ischemic stroke (stroke) remains unclear.
Purpose of the Study:
- To investigate how patient cognitive status—normal cognition (NC), mild cognitive impairment (MCI), or early-stage dementia—influences physician recommendations for guideline-concordant treatments after AMI and stroke.
- To assess disparities in recommended care based on cognitive impairment levels in older cardiovascular patients.
Main Methods:
- Two parallel, randomized survey studies were conducted in the US, utilizing clinical vignettes for AMI and stroke scenarios.
- Physicians (cardiologists, neurologists, generalists) were randomized to evaluate hypothetical patients with varying cognitive statuses (NC, MCI, early-stage dementia).
- The primary outcome measured was a composite quality score reflecting the number of guideline-concordant treatments recommended.
Main Results:
- A total of 1,031 physicians participated, with 980 providing complete data.
- Physicians recommended guideline-concordant treatments for AMI and stroke similarly for hypothetical patients with MCI compared to those with NC (adjusted ratio 0.98; P=0.36).
- Physicians recommended significantly fewer treatments for hypothetical patients with early-stage dementia compared to those with NC (adjusted ratio 0.90; P<0.001).
Conclusions:
- Physician recommendations for guideline-concordant AMI and stroke treatments were not significantly different for patients with MCI compared to those with NC.
- A notable disparity exists, with physicians recommending fewer treatments for patients with early-stage dementia compared to those with NC.
- These findings highlight potential under-treatment in patients with cognitive decline and underscore the need for interventions to ensure equitable cardiovascular care.
Background:
Clinical guidelines recommend that older patients (65+) with mild cognitive impairment (MCI) and early-stage dementia receive similar guideline-concordant care after cardiovascular disease (CVD) events as those with normal cognition (NC). However, older patients with MCI and dementia receive less care for CVD and other conditions than those with NC. Whether physician recommendations for guideline-concordant treatments after two common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke (stroke), differ between older patients with NC, MCI, and early-stage dementia is unknown.
Objective:
To test the influence of patient cognitive status (NC, MCI, early-stage dementia) on physicians' recommendations for guideline-concordant treatments for AMI and stroke.
Design:
We conducted two parallel, randomized survey studies for AMI and stroke in the US using clinical vignettes where the hypothetical patient's cognitive status was randomized between physicians.
Participants:
The study included cardiologists, neurologists, and generalists who care for most patients hospitalized for AMI and stroke.
Main Measures:
The primary outcome was a composite quality score representing the number of five guideline-concordant treatments physicians recommended for a hypothetical patient after AMI or stroke.
Key Results:
1,031 physicians completed the study (58.5% response rate). Of 1,031 respondents, 980 physicians had complete information. After adjusting for physician factors, physicians recommended similar treatments after AMI and stroke in hypothetical patients with pre-existing MCI (adjusted ratio of expected composite quality score, 0.98 [95% CI, 0.94, 1.02]; P = 0.36) as hypothetical patients with NC. Physicians recommended fewer treatments to hypothetical patients with pre-existing early-stage dementia than to hypothetical patients with NC (adjusted ratio of expected composite quality score, 0.90 [0.86, 0.94]; P < 0.001).
Conclusion:
In these randomized survey studies, physicians recommended fewer guideline-concordant AMI and stroke treatments to hypothetical patients with early-stage dementia than those with NC. We did not find evidence that physicians recommend fewer treatments to hypothetical patients with MCI than those with NC.
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