1105 — Statin discontinuation in Veterans Affairs (VA) Community Living Center residents with limited life expectancy

Lead/Presenter: Carolyn Thorpe,  COIN - Pittsburgh/Philadelphia
All Authors: Thorpe CT (Center for Health Equity Research and Promotion, Pittsburgh), Mor MK (Center for Health Equity Research and Promotion, Pittsburgh), Zhang S (Center for Health Equity Research and Promotion, Pittsburgh) Sileanu FE (Center for Health Equity Research and Promotion, Pittsburgh) Zhao X (Center for Health Equity Research and Promotion, Pittsburgh) Aspinall SL (Center for Health Equity Research and Promotion, Pittsburgh) Ersek MJ (Center for Health Equity Research and Promotion, Philadelphia) Hanlon JT (Center for Health Equity Research and Promotion, Pittsburgh) Hunnicutt J (Center for Health Equity Research and Promotion, Pittsburgh) Niznik JD (Center for Health Equity Research and Promotion, Pittsburgh) Springer S (Center for Health Equity Research and Promotion, Pittsburgh) Gellad WF (Center for Health Equity Research and Promotion, Pittsburgh) Schleiden LJ (Center for Health Equity Research and Promotion, Pittsburgh) Thorpe JM (Center for Health Equity Research and Promotion, Pittsburgh)

Objectives:
Expert consensus panels recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD), but studies show that many nursing home (NH) residents with LLE/AD receive statins. This study examined resident and facility factors predicting statin discontinuation after Community Living Center (CLC) admission in Veterans with LLE/AD taking statins for secondary prevention.

Methods:
This was a national, retrospective cohort study of Veterans admitted to VA CLCs in fiscal years 2009-15. Data sources included the VA Residential History File, Minimum Dataset (MDS), daily medication administration data, VA Corporate Data Warehouse, and Medicare claims. Inclusion criteria were LLE/AD at admission, age ?65, history of coronary artery disease, stroke, or diabetes, and statin use at admission (n = 13,110). Residents were followed from first day of statin use until discontinuation (i.e., gap in statin use ?14 days) or censoring due to discharge, death, or day 91 of the CLC stay. Fine and Gray subdistribution hazard models with death as a competing risk were used to assess predictors of discontinuation.

Results:
The sample was 99% male, 79% White, and 28% aged ?85. The cumulative incidence of statin discontinuation was 31.6% (95% CI = 30.6%, 32.7%) by day 91 of follow-up. The strongest predictor of discontinuation was explicit documentation of < 6 months prognosis or hospice at admission (adjusted SHR = 3.11, 95% CI = 2.73, 3.53). Other factors associated with greater hazard of discontinuation included older age, advanced dementia, weight loss, poor appetite, dehydration, recent acute change in mental status, cancer, dependency in activities of daily living, severe aggressive behavior, pain, and swallowing difficulty. Conversely, admission from home/assisted living vs. hospital and being obese or overweight predicted lower hazard of discontinuation.

Implications:
Most Veterans admitted to VA CLCs with LLE/AD taking statins for secondary prevention do not have these medications discontinued after admission. Deprescribing appears to be largely influenced by resident factors indicating poor prognosis.

Impacts:
Greater efforts to deprescribe unnecessary statins in older VA CLC residents with limited life expectancy, particularly those without limited prognosis or hospice receipt explicitly documented at CLC admission, may be warranted.