Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America.
Department of Neurology and Stroke Program, U-M, Ann Arbor, MI, United States of America.
PLoS One. 2020 Mar 17;15(3):e0230446. doi: 10.1371/journal.pone.0230446. eCollection 2020.
Evidence suggests that older adults with mild cognitive impairment (MCI) might not receive evidence-based treatments. We explored the impact of patient MCI on physician decision-making and recommendations for acute ischemic stroke (AIS) and acute myocardial infarction (AMI) in a pilot concurrent mixed-methods study of physicians recruited from one academic center. The mailed survey included a clinical vignette of AIS or AMI where the patient cognitive status was randomized (normal cognition, MCI, or early-stage dementia). The primary outcome was a composite summary measure of the proportion of guideline-concordant treatments recommended. Linear regression compared the primary outcome across patient cognition groups adjusting for physician characteristics. Semi-structured interviews done with 18 physicians (4 cardiologists, 9 neurologists, 5 internists) using a standard guide. Survey response rate was 72% (82/114) (49/61 neurologists; 33/53 cardiologists). As patient cognition worsened, neurologists recommended less guideline-concordant treatments after AIS (Ptrend<0.001 across patient cognition groups). Cardiologists did not after AMI (Ptrend = 0.11) in adjusted analyses. Neurologists' recommendation of guideline-concordant treatments after AIS was non-significantly lower in patients with MCI (composite measure, 0.13 points lower; P = 0.14) and significantly lower in patients with early-stage dementia (0.33 points lower; P<0.001) compared to cognitively normal patients. Interviews identified themes that may explain these findings including physicians assumed patients with MCI, compared with cognitively normal patients, have limited life expectancy, frailty and poor functioning, prefer less treatment, might adhere less to treatment, and have greater risks or burdens from treatment. These results suggest that patient MCI influences physician decision-making and recommendations for AIS and AMI treatments.
有证据表明，轻度认知障碍（MCI）的老年人可能无法接受基于证据的治疗。我们在一项针对一家学术中心招募的医生的试点性同期混合方法研究中，探讨了患者 MCI 对急性缺血性中风（AIS）和急性心肌梗死（AMI）的医生决策和建议的影响。邮寄调查包括 AIS 或 AMI 的临床病例，患者认知状态随机（正常认知、MCI 或早期痴呆）。主要结果是推荐的符合指南治疗的综合指标。线性回归比较了主要结果，调整了医生特征。使用标准指南对 18 名医生（4 名心脏病专家、9 名神经科医生、5 名内科医生）进行了半结构访谈。调查的回复率为 72%（82/114）（61 名神经科医生中有 49 名；53 名心脏病医生中有 33 名）。随着患者认知能力的下降，神经科医生在 AIS 后推荐的不符合指南的治疗方法减少（随着患者认知能力的变化，趋势 P<0.001）。在调整分析中，心脏病医生在 AMI 后没有（趋势 P=0.11）。在 AIS 后，神经科医生推荐的符合指南的治疗方法在 MCI 患者中明显较低（综合指标低 0.13 分；P=0.14），在早期痴呆患者中明显较低（低 0.33 分；P<0.001）与认知正常的患者相比。访谈确定了可能解释这些发现的主题，包括医生认为与认知正常的患者相比，MCI 患者的预期寿命有限、体弱多病和功能较差、更喜欢较少的治疗、可能不太遵守治疗、以及治疗的风险或负担更大。这些结果表明，患者 MCI 影响了 AIS 和 AMI 治疗的医生决策和建议。
