The effects of geriatric aortic stenosis education and its implications on heart failure prevention in medically underserved communities

Given our progressively aging population, aortic stenosis has become the most common cause of valvular heart disease, affecting 12.4% of people >75 years of age, with no consistent means of prevention.1,–3 Age-related aortic stenosis usually begins after the age of 60 with gradual calcification of the aortic valve that obstructs the left ventricular outflow tract of the heart, resulting in a pressure overload that, if left untreated, leads to heart failure.1,4 Severe aortic stenosis has the capability of quickly escalating to a poor prognosis, with a mortality rate as high as 50% at one year.1 The presentation of aortic stenosis can be challenging owing to the high frequency of low gradient severe aortic stenosis, meaning patients may present without any symptoms until the acute-onset of heart failure.5 Previous research focused directly on aortic stenosis prevention, such as lowering serum levels of calcium or phosphate, but this association has been inconsistent.3 Other studies have shown that adoption of the American Heart Association’s, “Life’s Simple 7,” which implements lifestyle modifications to achieve ideal cardiovascular health, could reduce the burden of aortic stenosis by as much as 55%, but data is limited.6 Based on 1996–2011 data from the Medical Expenditure Panel Survey, the largest aggregate annual costs incurred by patients in the US with symptomatic and asymptomatic aortic stenosis was US$5.6bn and US$4.6bn, respectively.7 With delayed aortic stenosis treatment, heart failure ensues, costing the US health care system over US$26bn annually, making it the most expensive of the Medicare diagnoses in the US.8 Given advancements with minimally-invasive techniques for aortic valve replacement in patients with severe aortic stenosis, almost any patient can receive treatment, so providing this knowledge to the geriatric population is critical towards heart failure prevention.4 Knowledge level on the topic of aortic stenosis was previously collected in a large cohort of over 8800 participants in Europe, which showed that knowledge of aortic stenosis was sparse, with 41.1% of respondents saying that following education they were more concerned about aortic stenosis.4 In Europe, approximately one million people over 75 years old suffer from severe aortic stenosis, thus an estimated 15 patients with any grade of aortic stenosis and four patients with severe aortic stenosis could be potentially identified with earlier screening.2 In addition, the overall survival rate of aortic stenosis has been shown to be 90% at two years and 70–87% at 4–5 years after diagnosis in asymptomatic severe aortic stenosis, with significant improvement in quality of life.5 To our knowledge, there have been no studies done focusing on using patient education to promote earlier screening for aortic stenosis in either the US or Europe. Therefore, the goal of the study is to increase confidence in knowledge (CIK) of aortic stenosis in geriatric populations, particularly those in medically underserved communities, ultimately promoting earlier screening, expediting the cardiology referral process in patients who receive the diagnosis, and preventing the onset of heart failure. Institutional review board (IRB) approval was obtained from the Central Michigan University IRB. The instruments used included a primary survey and follow-up survey that assessed participants’ CIK of aortic stenosis, participants’ confidence that their primary care provider (PCP) will provide the necessary information about the signs and symptoms of aortic stenosis, and participants’ satisfaction with their current treatment and care. The follow-up survey was administered 30–60 days later. Participants’ CIK and satisfaction were collected through the use of a Likert scale (1–5), where 1 was strongly disagree and 5 was strongly agree. Questions were adopted from the American College of Cardiology (ACC) “Championing Care for the Patient with Aortic Stenosis” initiative.9 Educational Intervention (EdI) at the time of the primary survey was provided using brochures from the ACC and Alliance for Aging Research. Participants were cognitively intact individuals aged 60 years and older, as measured by the Mini-Mental Status Exam. Survey collection took place at Senior Services facilities and Community Farmers’ Markets. Statistical analysis used SPSS Statistics version 25.0 (IBM, Armonk, New York, USA). Data was analyzed using descriptive, two sample t-test and logistics regression to examine the association between variables and binary response. Whether knowledge has changed after educational intervention was examined by McNemar. Analysis of variance was used to test whether averages were different among multiple groups. All of the analytical results were considered to be significant when p-values were less than or equal to 0.05. One hundred and fifty-eight participants were enrolled from eight medically underserved rural and urban Michigan counties (Table 1). After EdI, participants had a 71% increase in CIK of heart valve problems and aortic stenosis (p < 0.0001). Specifically, after EdI, participants had more CIK in knowing the symptoms for heart valve problems, demonstrating knowledge that heart valve problems may not have any symptoms, awareness of the treatment options for aortic stenosis, the pros and cons of treatment options for aortic stenosis, and knowing which healthcare providers to contact if they had any heart-related problems (p < 0.0001). At follow-up, 30% of participants felt inclined to see a PCP as a result of our EdI. Of the 27.6% of participants who endorsed symptoms of aortic stenosis, 12.5% inclined to see a physician following EdI. There was an increase in confidence that participants’ PCPs would educate them on what a heart valve problem was post EdI (p < 0.001). This is likely due to participants’ newfound confidence to initiate discussion of aortic stenosis at scheduled clinic visits. Mean participant agreement increased regarding involvement in medical decision making (p = 0.042) with evidence to conclude that confidence in “knowing a lot about heart valve problems” was positively correlated with an increased role for the participant and their family in medical decision making (p = 0.024). As suggested by evidence-based-practice, involvement of patients in shared decision making results in increased patient satisfaction, better quality of care, and thus improved healthcare outcomes.9,10 Medically underserved primary survey demographics. Total participants enrolled = 158. Definition of Index of Medically Underserved (IMU) score: an index created by the US Department of Health and Human Services based on data on a medical service area of the USA to obtain a score for the area. The IMU scale is a percentage from 0 to 100: a score of 0% represents a completely underserved area; 100% represents best served/least underserved. Under established criteria, any service area with an IMU of ≤62.0% qualifies as a medically underserved area. The IMU involves four variables: ratio of primary medical care physicians per 1000 population; infant mortality rate; percentage of the population with incomes below the poverty level; and percentage of the population aged 65 years or over. Governor’s Exceptional Medically Underserved Population – exempt from IMU score. PCP: primary care provider Medically underserved primary survey demographics. Total participants enrolled = 158. Definition of Index of Medically Underserved (IMU) score: an index created by the US Department of Health and Human Services based on data on a medical service area of the USA to obtain a score for the area. The IMU scale is a percentage from 0 to 100: a score of 0% represents a completely underserved area; 100% represents best served/least underserved. Under established criteria, any service area with an IMU of ≤62.0% qualifies as a medically underserved area. The IMU involves four variables: ratio of primary medical care physicians per 1000 population; infant mortality rate; percentage of the population with incomes below the poverty level; and percentage of the population aged 65 years or over. Governor’s Exceptional Medically Underserved Population – exempt from IMU score. PCP: primary care provider The CIK of aortic stenosis was sparse in medically underserved communities, but our EdI promoted its awareness and inclined participants to see their PCPs, thus promoting earlier screening. In addition, increased CIK of aortic stenosis was positively correlated with participants being more involved in determining their treatment choices and having more confidence in their PCPs’ ability to provide aortic stenosis education. Therefore, patient education provides a means for addressing the lack of knowledge on aortic stenosis, and for promoting earlier aortic stenosis screening throughout the US and Europe. We would like to thank the following medical students and the research fellow for assisting with data collection: Kathrin Parisi, Alexandra Gamber, Brandon Govan, Jason LaFave, Sara Robinson, Emmanuel Avelino and Jacob Kurdys.