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Background: People with mild cognitive impairment (MCI) receive fewer guideline-concordant treatments for cardiovascular disease (CVD) than people with normal cognition (NC). Objective: To understand physician perspectives on why patients with MCI receive fewer CVD treatments than patients with NC. Methods: As part of a mixed-methods study assessing how patient MCI influences physicians’ decision making for acute myocardial infarction (AMI) and stroke treatments, we conducted a qualitative study using interviews of physicians. Topics included participants’ reactions to data that physicians recommend fewer CVD treatments to patients with MCI and reasons why participants think fewer CVD treatments may be recommended to this patient population. Results: Participants included 22 physicians (8 cardiologists, 7 neurologists, and 7 primary care physicians). Most found undertreatment of CVD in patients with MCI unreasonable, while some participants thought it could be considered reasonable. Participants postulated that other physicians might hold beliefs that could be reasons for undertreating CVD in patients with MCI. These beliefs fell into four main categories: 1) patients with MCI have worse prognoses than NC, 2) patients with MCI are at higher risk of treatment complications, 3) patients’ cognitive impairment might hinder their ability to consent or adhere to treatment, and 4) patients with MCI benefit less from treatments than NC. Conclusion: These findings suggest that most physicians do not think it is reasonable to recommend less CVD treatment to patients with MCI than to patients with NC. Improving physician understanding of MCI might help diminish disparities in CVD treatment among patients with MCI.

Background: Older adults with mild cognitive impairment (MCI) receive fewer guideline-concordant treatments for multiple health conditions than those with normal cognition. Reasons for this disparity are unclear. Objective: To better understand this disparity, we describe physician understanding and experience with patient MCI, particularly physician identification of MCI, ability to distinguish between MCI and dementia, and perspectives on education and training in MCI and dementia. Methods: As part of a mixed-methods study assessing the influence of patient MCI on physician recommendations for acute myocardial infraction and stroke treatments, we conducted a descriptive qualitative study using semi-structured interviews of physicians from three specialties. Key question topics included participants’ identification of MCI, impressions of MCI and dementia awareness within their practice specialty, and perspectives on training and education in MCI. Results: The study included 22 physicians (8 cardiologists, 7 neurologists, and 7 internists). We identified two primary themes: There is 1) a lack of adequate understanding of the distinction between MCI and dementia; and 2) variation in physician approaches to identifying whether an older adult has MCI. Conclusion: These findings suggest that physicians have a poor understanding of MCI. Our results suggest that interventions that improve physician knowledge of MCI are needed.

Background: Older patients (≥65 years) with mild cognitive impairment (MCI) are undertreated for cardiovascular disease (CVD). One reason for this disparity could be that patients with MCI might underestimate the chances of CVD and overestimate dementia. Objective: To compare conceptions of health risk between older patients with MCI and normal cognition (NC) and their care partners. Methods: We conducted a multi-center mixed-methods study of patient-care partner dyads completing written quantitative surveys (73% response rate; 127 dyads: 66 MCI and 61 NC) or semi-structured interviews (20 dyads: 11 MCI, and 9 NC). Surveys assessed two-year patient risks of dementia, heart attack, stroke, and fall. Interviews assessed similar health risks and reasons for risk perceptions. Results: On surveys, a similarly low proportion of MCI and NC patients felt they were at risk of stroke (5% versus 2%; p = 0.62) and heart attack (2% versus 0%; p = 0.99). More MCI than NC patients perceived dementia risk (26% versus 2%; p

Background: Older patients with mild cognitive impairment (MCI) should receive evidence-based treatments when clinically indicated. However, patients with MCI appear less likely than cognitively normal patients to receive evidence-based treatments. Objective: To explore the influence of a patient’s MCI diagnosis on physician decision-making. Methods: Qualitative study of 18 physicians from cardiology, neurology, and internal medicine using semi-structured interviews. We sought to understand whether and how a patient’s having MCI has influenced physicians’ decisions about five categories of treatments or tests (surgery, invasive tests, non-invasive tests, rehabilitation, and preventive medication). We used qualitative content analysis to identify the unifying and recurrent themes. Results: Most physician participants described MCI as influencing their recommendations for at least one treatment or test. We identified two major themes as factors that influenced physician recommendations in patients with MCI: Physicians assume that MCI patients’ decreased cognitive ability will impact treatment; and physicians assume that MCI patients have poor health status and physical functioning that will impact treatment. These two themes were representative of physician beliefs that MCI patients have impaired independent decision-making, inability to adhere to treatment, inability to communicate treatment preferences, and increased risk and burden from treatment. Conclusion: A patient’s MCI diagnosis influences physician decision-making for treatment. Some physician assumptions about patients with MCI were not evidence-based. This phenomenon potentially explains why many patients with MCI get fewer effective treatments or tests than cognitively normal patients. Interventions that improve how physicians understand MCI and make decisions for treatments in patients with MCI are needed.

Background: Mild cognitive impairment (MCI) is common, affecting up to 1 in 5 adults 65 or older. Although it is known that physicians recommend fewer treatments for stroke and acute myocardial infarction (AMI) to patients with pre-existing dementia, it is unknown how pre-existing MCI influences physician recommendations for stroke and AMI treatments. Methods: Qualitative study based on in-depth, semi-structured, in-person interviews with physicians from 2 academic medical centers. We interviewed neurologists (n=7), primary care physicians (n=7), and cardiologists (n=7) using a standard guide. Qualitative content analysis was used to identify unifying and recurrent themes. Participants were asked to reflect on data from a pilot study suggesting that physicians recommended fewer treatments for stroke and AMI to older adults with MCI. Responses between specialties were compared. Results: Participants postulated reasons that fewer stroke and AMI treatments were recommended to MCI patients (Table 1). The most common reasons were that physicians may assume patients with MCI have a poor prognosis, quality of life, or will soon progress to dementia (71%), that treatments are risky or harmful (67%), and that patients with MCI won’t comply with treatment (52%). Neurologists more frequently assumed that patients with MCI benefit less from stroke treatments. Whereas, cardiologists often thought that patients with MCI face greater risks from AMI treatments. All three specialties felt that physicians made assumptions that patients with MCI are not able to comply with treatment. Conclusion: Physicians may think that patients with MCI are more likely to have a poor prognosis, benefit less from treatments, and/or face greater risks from treatments than cognitively normal patients. Such beliefs may lead physicians to recommend fewer treatments for stroke and AMI to patients with MCI.

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

Objective Although smoking cessation is a key priority emphasized by professional societies and multidisciplinary consensus guidelines, significant variation exists in the methods and efficacy of smoking cessation treatment practiced by vascular surgeons. We conducted a series of patient, surgeon, and nonpatient stakeholder focus groups to identify important domains for establishment of a successful smoking cessation program. Methods As part of a planning effort for a randomized clinical trial on usual care vs a standardized, evidence-based smoking cessation intervention, our group performed a series of interviews and focus groups. These were four 1-hour interviews, conducted with stakeholders such as tobacco cessation counselors (n = 2), a Quit Line representative (n = 1), and a Vascular Quality Initiative leader (n = 1), as well as two 90-minute, formal, professionally moderated focus groups, one with vascular surgeons (n = 7), and another with patients (n = 4). Transcripts and audio recordings were qualitatively reviewed for themes to establish the most important domains perceived to be associated with a successful smoking cessation program. Results Patients emphasized four domains critical for a successful smoking cessation program: the motivation to quit, an individualized approach, the timing of an intervention, and the tone of the physician who offers counseling. Although surgeons and nonpatient stakeholders also emphasized the importance of a compassionate physician tone, surgeons and nonpatient stakeholders differed from patients in their remaining domains. They emphasized the feasibility of a brief intervention in a busy clinical practice, implementation of the effort, and necessary infrastructure for smoking cessation programs. All focus group participants described a brief, evidence-based smoking cessation intervention as feasible in routine vascular practice. Conclusions Differences in motivation and significance exist for patients, surgeons, and stakeholders when they considered the specific domains most important in building a successful smoking cessation program. Despite these differences, all parties involved agreed that a brief, standardized intervention can be successful delivered in a busy vascular clinic setting.