Person: Mitchell, Susan
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Mitchell
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Mitchell, Susan
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Publication Patient Activity and Survival Following Implantable Cardioverter-Defibrillator Implantation: The ALTITUDE Activity Study(John Wiley & Sons, Ltd, 2015) Kramer, Daniel; Mitchell, Susan; Monteiro, Joao; Jones, Paul W; Normand, Sharon-Lise; Hayes, David L; Reynolds, Matthew RBackground: Physical activity data are collected automatically by implantable cardioverter-defibrillators (ICDs). Though these data potentially provide a quantifiable and easily accessible measure of functional status, its relationship with survival has not been well studied. Methods and Results: Patients enrolled in the Boston Scientific LATITUDE remote monitoring system from 2008 to 2012 with ICDs were eligible. Remote monitoring data were used to calculate mean daily activity at baseline (30 to 60 days after implantation), and longitudinally. Cox regression was used to examine the association between survival and increments of 30 minutes/day in both (1) mean baseline activity and (2) time-varying activity, with both adjusted for demographic and device characteristics. A total of 98 437 patients were followed for a median of 2.2 years (mean age of 67.7±13.1 years; 71.7% male). Mean baseline daily activity was 107.5±66.2 minutes/day. The proportion of patients surviving after 4 years was significantly higher among those in the most versus least active quintile of mean baseline activity (90.5% vs. 50.0%; log-rank P value, <0.001). Lower mean baseline activity (i.e., incremental difference of 30-minutes/day) was independently associated with a higher risk of death (adjusted hazard ratio [AHR], 1.44; 95% confidence interval [CI], 1.427 to 1.462). Time-varying activity was similarly associated with a higher risk of death (AHR, 1.48; 95% CI, 1.451 to 1.508), indicating that a patient having 30 minutes per day less activity in a given month has a 48% increased hazard for death when compared to a similar patient in the same month. Conclusions: Patient activity measured by ICDs strongly correlates with survival following ICD implantation.Publication Frailty, Physical Activity, and Mobility in Patients With Cardiac Implantable Electrical Devices(John Wiley and Sons Inc., 2017) Kramer, Daniel; Tsai, Timothy; Natarajan, Poorna; Tewksbury, Elise; Mitchell, Susan; Travison, ThomasBackground: This study aimed to demonstrate the feasibility of measuring frailty in patients with cardiac implantable electrical devices while validating the physiologic significance of device‐detected physical activity by evaluating its association with frailty and mobility. Methods and Results: Outpatients with cardiac implantable electrical devices compatible with physical activity analysis with at least 7 days of data were eligible. Office testing included frailty status (Study of Osteoporotic Fractures instrument), gait speed (m/s), mobility according to the Timed Up and Go (TUG) test (seconds), and daily physical activity (h/d) as measured by cardiac implantable electrical device. Among 219 patients, Study of Osteoporotic Fractures testing found 39.7% to be robust, 47.5% prefrail, and 12.8% frail. The mean gait speed for the cohort was 0.8±0.3 m/s, mean TUG time was 10.9±4.4 seconds, and mean activity was 2.8±1.9 h/d. Frail patients were markedly more likely to have gait speeds <0.8 m/s (OR 6.25, 95% CI 1.79‐33.3). In unadjusted analyses each 1‐hour increase in mean daily activity was associated with a 46% reduction of frail phenotype (OR 0.54, 95% CI 0.40‐0.74) versus robust and with a 27% reduction in the odds of having the prefrail phenotype (OR 0.73, 95% CI 0.62‐0.86). After adjustment this association per hour of activity persisted, with an adjusted OR for frailty of 0.71 (95% CI 0.51‐0.99) and adjusted OR for prefrailty of 0.81 (95% CI 0.67‐0.99). Conclusions: Frailty and mobility limitation are common among cardiac implantable electrical device patients and are correlated to device‐detected physical activity.Publication The Decisions, Interventions, and Goals in ImplaNtable Cardioverter‐DefIbrillator TherapY (DIGNITY) Pilot Study(John Wiley and Sons Inc., 2017) Kramer, Daniel; Habtemariam, Daniel; Adjei‐Poku, Yaw; Samuel, Michelle; Engorn, Diane; Reynolds, Matthew R.; Mitchell, SusanBackground: Implantable cardioverter‐defibrillators (ICDs) are commonly implanted in older patients, including those with multiple comorbidities. There are few prospective studies assessing the clinical course and end‐of‐life circumstances for these patients. Methods and Results: We prospectively followed 51 patients with ICDs for up to 18 months to longitudinally assess in terms of (1) advance care planning, (2) health status, (3) healthcare utilization, and (4) end‐of‐life circumstances through quarterly phone interviews and electronic medical record review. The mean age was 71.1±8.3, 74.5% were men, and 19.6% were non‐white. Congestive heart failure was predominant (82.4%), as was chronic kidney disease (92%). At baseline, a total of 12% of subjects met criteria for major depression, and 78.4% met criteria for mild cognitive impairment. From this initial study cohort, 76% survived to 18 months and completed all follow‐up interviews, 18% died, and 19% withdrew or were lost to follow‐up. Though living will completion and healthcare proxy assignment were common (cumulative outcome at 18 months 88% and 98%, respectively), discussions of prognosis were uncommon (baseline, 9.8%; by 18 months, 22.7%), as were conversations regarding ICD deactivation (baseline, 15.7%; by 18 months, 25.5%). Five decedents with available data received shocks in the days immediately prior to death, including 3 of whom ultimately had their ICDs deactivated prior to death. Conclusions: We demonstrated the feasibility of prospective enrollment and follow‐up of older, vulnerable ICD patients. Early findings suggest a high burden of cognitive and psychological impairment, poor communication with providers, and frequent shocks at the end of life. These findings will inform the design of a larger cohort study designed to further explore the experiences of living and dying with an ICD in this important patient population.Publication Hospice Use Following Implantable Cardioverter-Defibrillator Implantation in Older Patients: Results From the National Cardiovascular Data Registry(Lippincott Williams & Wilkins, 2016) Kramer, Daniel; Reynolds, Matthew R.; Normand, Sharon-Lise; Parzynski, Craig S.; Spertus, John A.; Mor, Vincent; Mitchell, SusanBackground— Older recipients of implantable cardioverter-defibrillators (ICDs) are at increased risk for short-term mortality in comparison with younger patients. Although hospice use is common among decedents aged >65, its use among older ICD recipients is unknown. Methods and Results— Medicare patients aged >65 matched to data in the National Cardiovascular Data Registry – ICD Registry from January 1, 2006 to March 31, 2010 were eligible for analysis (N=194 969). The proportion of ICD recipients enrolled in hospice, cumulative incidence of hospice admission, and factors associated with time to hospice enrollment were evaluated. Five years after device implantation, 50.9% of patients were either deceased or in hospice. Among decedents, 36.8% received hospice services. The cumulative incidence of hospice enrollment, accounting for the competing risk of death, was 4.7% (95% confidence interval [CI], 4.6%–4.8%) within 1 year and 21.3% (95% CI, 20.7%–21.8%) at 5 years. Factors most strongly associated with shorter time to hospice enrollment were older age (adjusted hazard ratio, 1.77; 95% CI, 1.73–1.81), class IV heart failure (versus class I; adjusted hazard ratio, 1.79; 95% CI, 1.66–1.94); ejection fraction <20 (adjusted hazard ratio, 1.57; 95% CI, 1.48–1.67), and greater hospice use among decedents in the patients’ health referral region. Conclusions— More than one-third of older patients dying with ICDs receive hospice care. Five years after implantation, half of older ICD recipients are either dead or in hospice. Hospice providers should be prepared for ICD patients, whose clinical trajectories and broader palliative care needs require greater focus.Publication Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment(American Medical Association (AMA), 2008-10-08) Wright, Alexi; Zhang, Baohui; Ray, Alaka; Mack, Jennifer; Trice, Elizabeth; Balboni, Tracy; Mitchell, Susan; Jackson, Vicki; Block, Susan; Maciejewski, Paul; Prigerson, HollyContext Talking about death can be difficult. Without evidence that end-of-life (EOL) discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern that EOL discussions may inflict psychological harm. Objective To determine whether EOL discussions with physicians are associated with fewer aggressive interventions. Design, Setting, Participants A United States multi-site, prospective, longitudinal cohort study of advanced cancer patients and their informal caregivers (n=332 dyads), September 2002-February 2008. Patients were followed from enrollment to death a median of 4.4 months later. Bereaved caregivers’ psychiatric illness and quality of life (QoL) was assessed a median 6.5 months later. Main Outcome Measures The primary outcome were aggressive medical care (e.g., ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients’ mental health and caregivers’ bereavement adjustment. Results 123 of 332 (37.0%) patients reported EOL discussions before baseline. EOL discussions were not associated with higher rates of Major Depressive Disorder (8.3% vs. 5.8; AOR 1.33, 95% CI 0.54-3.32), or more “worry” (6.5 vs. 7.0; p=0.19)). After propensity-score weighted adjustment, EOL discussions were associated with lower rates of ventilation (1.6% vs. 11.0%; AOR 0.26, 95% CI 0.08-0.83), resuscitation (0.8% vs. 6.7%; AOR 0.16, 95% CI 0.03-0.80), ICU admission (4.1 vs. 12.4%; AOR 0.35, 95% CI 0.14-0.90), and earlier hospice enrollment (65.6% vs. 44.5%; AOR 1.58, 95% CI 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient QoL (6.4 vs. 4.6; F=3.60, p=0.01) and higher risk for Major Depressive Disorder in bereaved caregivers (AOR 3.37, 95% CI 1.12-10.13), while longer hospice stays were associated with better patient QoL (5.6 vs. 6.9; F=3.70, p=0.01). Better patient QoL was associated with better caregiver QoL at follow-up (β=0.20; p=0.001). Conclusion EOL discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient QoL and worse bereavement adjustment.Publication Mortality and Readmission After Cervical Fracture from a Fall in Older Adults: Comparison with Hip Fracture Using National Medicare Data(Wiley-Blackwell, 2015) Cooper, Zara; Mitchell, Susan; Lipsitz, Stuart; Harris, Mitchel; Ayanian, John; Bernacki, Rachelle; Jha, AshishBackground Cervical fractures from falls are a potentially lethal injury in older patients. Little is known about their epidemiology and outcomes. Objectives To examine the prevalence of cervical spine fractures after falls among older Americans and show changes in recent years. Further, to compare 12-month outcomes in patients with cervical and hip fracture after falls. Design, Setting, and Participants A retrospective study of Medicare data from 2007–2011 including patients ≥65 with cervical fracture and hip fracture after falls treated at acute care hospitals. Measurements Rates of cervical fracture, 12-month mortality and readmission rates after injury. Results Rates of cervical fracture increased from 4.6/10,000 in 2007 to 5.3/10,000 in 2011, whereas rates of hip fracture decreased from 77.3/10,000 in 2007 to 63.5/10,000 in 2011. Patients with cervical fracture without and with spinal cord injury (SCI) were more likely than patients with hip fracture, respectively, to receive treatment at large hospitals (54.1%, 59.4% vs. 28.1%, p< 0.001), teaching hospitals (40.0%, 49.3% vs. 13.4%, p< 0.001), and regional trauma centers (38.5%, 46.3% vs. 13.0%, p< 0.001). Patients with cervical fracture, particularly those with SCI, had higher risk-adjusted mortality rates at one year than those with hip fracture (24.5%, 41.7% vs. 22.7%, p<0.001). By one year, more than half of patients with cervical and hip fracture died or were readmitted to the hospital (59.5%, 73.4% vs. 59.3%, p<0.001). Conclusion Cervical spine fractures occur in one of every 2,000 Medicare beneficiaries annually and appear to be increasing over time. Patients with cervical fractures had higher mortality than those with hip fractures. Given the increasing prevalence and the poor outcomes of this population, hospitals need to develop processes to improve care for these vulnerable patients.Publication Predictors of Mortality Up to 1 Year After Emergency Major Abdominal Surgery in Older Adults(Wiley-Blackwell, 2015) Cooper, Zara; Mitchell, Susan; Gorges, Rebecca J.; Rosenthal, Ronnie A.; Lipsitz, Stuart; Kelley, Amy Packground The number of older patients who undergo emergent major abdominal procedures is expected to increase yet little is known about mortality beyond 30 days after surgery. Objective Identify factors associated with mortality among older patients at 30, 180 and 365 days after emergency major abdominal surgery. Design A retrospective study of the Health and Retirement Study (HRS) linked to Medicare Claims from 2000-2010. Setting N/A Participants Medicare beneficiaries > 65.5 years enrolled in the Health and Retirement Study (HRS) from 2000-2010, with at least one urgent/emergent major abdominal surgery and a core interview from the HRS within 3 years prior to surgery. Main Outcomes and Measures Survival analysis was used to describe all-cause mortality at 30, 180 and 365 days after surgery. Complementary log-log regression was used to identify patient characteristics and postoperative events associated with worse survival. Results 400 patients had one of the urgent/emergent surgeries of interest. Of these 24% were > 85 years; 50% had coronary artery disease, 48% had cancer, and 33% had congestive heart failure; and 37% experienced a postoperative complication. Postoperative mortality was 20%, 31% and 34% at 30, 180 days and 365 days. Among those > 85 years, 50% were dead one year after surgery. After multivariate adjustment including postoperative complications, dementia (Hazard ratio (HR) 2.02, 95%CI 1.24-3.31), hospitalization within 6 months before surgery (HR 1.63, 95% CI 1.12-2.28) and complications (HR 3.45, 95%CI (2.32-5.13) were independently associated with worse one-year survival. Conclusion Overall mortality is high up to one year after surgery in many older patients undergoing emergency major abdominal surgery. The occurrence of a complication is the clinical factor most strongly associated with worse survival.Publication Use of Video to Facilitate End-of-Life Discussions With Patients With Cancer: A Randomized Controlled Trial(American Society of Clinical Oncology (ASCO), 2010) El-Jawahri, Areej; Podgurski, Lisa M.; Eichler, April; Plotkin, Scott; Temel, Jennifer; Mitchell, Susan; Chang, Yuchiao; Barry, Michael; Volandes, AngeloPurpose To determine whether the use of a goals-of-care video to supplement a verbal description can improve end-of-life decision making for patients with cancer. Methods Fifty participants with malignant glioma were randomly assigned to either a verbal narrative of goals-of-care options at the end of life (control), or a video after the same verbal narrative (intervention) in this randomized controlled trial. The video depicts three levels of medical care: life-prolonging care (cardiopulmonary resuscitation [CPR], ventilation), basic care (hospitalization, no CPR), and comfort care (symptom relief). The primary study outcome was participants' preferences for end-of-life care. The secondary outcome was participants' uncertainty regarding decision making (score range, 3 to 15; higher score indicating less uncertainty). Participants' comfort level with the video was also measured. Results Fifty participants were randomly assigned to either the verbal narrative (n = 27) or video (n = 23). After the verbal description, 25.9% of participants preferred life-prolonging care, 51.9% basic care, and 22.2% comfort care. In the video arm, no participants preferred life-prolonging care, 4.4% preferred basic care, 91.3% preferred comfort care, and 4.4% were uncertain (P < .0001). The mean uncertainty score was higher in the video group than in the verbal group (13.7 v 11.5, respectively; P < .002). In the intervention arm, 82.6% of participants reported being very comfortable watching the video. Conclusion Compared with participants who only heard a verbal description, participants who viewed a goals-of-care video were more likely to prefer comfort care and avoid CPR, and were more certain of their end-of-life decision making. Participants reported feeling comfortable watching the video.Publication Video Decision Support Tool for Advance Care Planning in Dementia: Randomised Controlled Trial(BMJ Publishing Group Ltd., 2009) Abbo, Elmer D; Volandes, Angelo; Paasche-Orlow, Michael K; Barry, Michael; Gillick, Muriel; Minaker, Kenneth L.; Chang, Yuchiao; Cook, Earl; El-Jawahri, Areej; Mitchell, SusanObjective: To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks. Design: Randomised controlled trial conducted between 1 September 2007 and 30 May 2008. Setting: Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston. Participants: Convenience sample of 200 older people (≥65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women. Intervention: Verbal narrative alone (n=106) or with a video decision support tool (n=94). Main outcome measures: Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care. Results: Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (χ2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (κ=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (κ=0.79) (P<0.001 for difference). Conclusion: Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.Publication Advanced Age and Post–Acute Care Outcomes After Subarachnoid Hemorrhage(John Wiley and Sons Inc., 2017) Fehnel, Corey; Gormley, William; Dasenbrock, Hormuzdiyar; Lee, Yoojin; Robertson, Faith; Ellis, Alexandra G.; Mor, Vincent; Mitchell, SusanBackground: Older patients with aneurysmal subarachnoid hemorrhage (aSAH) are unique, and determinants of post–acute care outcomes are not well elucidated. The primary objective was to identify hospital characteristics associated with 30‐day readmission and mortality rates after hospital discharge among older patients with aSAH. Methods and Results: This cohort study used Medicare patients ≥65 years discharged from US hospitals from January 1, 2008, to November 30, 2010, after aSAH. Medicare data were linked to American Hospital Association data to describe characteristics of hospitals treating these patients. Using multivariable logistic regression to adjust for patient characteristics, hospital factors associated with (1) hospital readmission and (2) mortality within 30 days after discharge were identified. A total of 5515 patients ≥65 years underwent surgical repair for aSAH in 431 hospitals. Readmission rate was 17%, and 8.5% of patients died within 30 days of discharge. In multivariable analyses, patients treated in hospitals with lower annualized aSAH volumes were more likely to be readmitted 30 days after discharge (lowest versus highest quintile, 1–2 versus 16–30 cases; adjusted odds ratio, 2.10; 95% confidence interval, 1.56–2.84). Patients treated in hospitals with lower annualized aSAH volumes (lowest versus highest quintile: adjusted odds ratio, 1.52; 95% confidence interval, 1.05–2.19) had a greater likelihood of dying 30 days after discharge. Conclusions: Older patients with aSAH discharged from hospitals treating lower volumes of such cases are at greater risk of readmission and dying within 30 days. These findings may guide clinician referrals, practice guidelines, and regulatory policies influencing which hospitals should care for older patients with aSAH.