Financial Strain Ups Risk of Death After Acute MI in the Elderly

A patient’s financial situation could be a marker of their mortality risk in the months after a hospital stay for acute MI, an analysis from the SILVER-MI study suggests.

“Older adults who were feeling stressed about money, whether or not they were in poverty prior to the hospitalization, were substantially less likely to survive,” Jason R. Falvey, PT, DPT, PhD (University of Maryland School of Medicine, Baltimore), told TCTMD. “That tells us that we need to be aware of these issues both before and during a hospitalization. Financially strained older adults are much more likely to skip taking medications, and they're much more likely to skip healthcare because of cost- or transit-related barriers.”

Falvey, whose study was published this week online ahead of print in JAMA Internal Medicine, said assessing for financial strain during hospitalization would allow the care team to set up appropriate resources to assist patients once they go home.

The fact that one question could discriminate such a high-risk group tells us that it's a way to quickly narrow down the pool of people we need to focus on. Jason Falvey

Khurram Nasir, MD, MPH (Houston Methodist, TX), who was not involved in the study, agreed that incorporation of financial hardship into risk assessment and management plans is important and often overlooked. Although the downstream pathways that lead financially strained patients to worse outcomes are not fully understood, a recent study from Nasir’s group found that one in eight patients can’t afford to take their medications as prescribed, often despite being on Medicare and having a supplemental drug plan. Additionally, issues of health literacy in the postdischarge period may need to be addressed, he added.

“We should be screening for financial distress because irrespective of your comorbid conditions, we now have a flag or at least an indicator, that these individuals are three- to fourfold higher risk of mortality in the next 6 months,” Nasir said.

One Question Speaks Volumes About Risk

Falvey and colleagues analyzed data on 2,851 patients age 75 or older enrolled in the multicenter, longitudinal cohort SILVER-AMI trial who were discharged with complete data on financial strain. A self-reported measure, the question regarding financial strain categorized responses as: none (more than enough money to make ends meet each month), moderate (just enough to make ends meet), or severe (not enough to make ends meet).

Compared with patients reporting no financial strain, those who cited having severe strain had higher rates of CAD, HF, prior MI, diabetes, PAD, sleep apnea, and kidney disease. They also had longer hospital stays and more geriatric vulnerabilities, including a weight loss of greater than 10 pounds in the last year and hearing impairment.

By 6 months, 7.2% of patients reporting no financial strain had died compared with 9.2% in the moderate strain group and 16.8% in the severe financial strain group. After adjustment for demographics, clinical factors, and conditions of aging, patients with severe financial strain had a 61% increased risk of mortality compared with those who reported no financial strain. No association with mortality was seen in the group reporting moderate financial strain, and no differences were seen after adjusting for sex in those with severe and moderate strain.

Falvey said unlike assessment of income and Medicaid eligibility, the financial strain question about making ends meet each month is “geographically agnostic” and simplifies the issue.

“The fact that one question could discriminate such a high-risk group tells us that it's a way to quickly narrow down the pool of people we need to focus on,” Falvey said. He said knowing a patient is experiencing severe financial strain could alert case managers, social workers, and clinicians to “take those extra steps for those high-risk patients and probe what those specific barriers are and what solutions we need to put in place.” A positive screen, Falvey and colleagues say, could guide targeted referrals for transportation, assistance with prescription drug co-payments, or medical equipment, among other things.

As physicians, we have discussions with patients on the most intimate things [such as] their depression, their sexual life, their drug history, but somehow discussion around cost has become taboo. Khurram Nasir

“As physicians, we have discussions with patients on the most intimate things [such as] their depression, their sexual life, their drug history, but somehow discussion around cost has become taboo,” Nasir observed. “It's time we break that and embrace it. It doesn't have to be completely physician-led. It's a team effort. But as the point person, I believe it's time physicians start to realize that financial hardship, inability to pay, all of these things are important components not only as far as risk, but also how we manage that risk.”

He added that the more physicians get into the habit of considering financial strain, the more “it becomes part and parcel of our risk assessment and management plan.” Importantly, Nasir said, improved physician recognition and advocacy around financial strain will be big steps toward influencing healthcare policy in that regard on a national level.

“It also will allow us to play an active role working with our local health systems and community financial assistance support programs, which exist, and which unfortunately many of us in the physician community don't realize,” he concluded.