The proposed K23 Beeson Career Development Award will establish me as independent investigator focusing on research that improves the lives of older adults with heart disease. I am a board-certified geriatrician and fellow in cardiology with training in health services research. My career goal is to improve the alignment of clinical care with the diverse health needs of older adults. I have previously used administrative data to study the complexity of hospitalized patients and the clinical epidemiology of 30-day readmissions. My objective in this proposal is to integrate my interests in aging and cardiology to examine the influence of multimorbidity and geriatric impairments on 30-day readmission following hospitalization for acute myocardial infarction (AMI). Neither multimorbidity nor geriatric impairments has been integrated into models predicting readmission even though both powerfully predict adverse outcomes and 1 in 5 older adults is readmitted within 30 days of hospitalization. To study this topic, I will use an explanatory sequential mixed- methods design in which quantitative findings are further developed by qualitative analysis. In Project 1, I will examine the association of baseline multimorbidity and geriatric impairments prior to hospitalization with 30- day readmission after AMI in over 500 older adults in the Medicare Current Beneficiary Survey. I hypothesize that risk increases with baseline multimorbidity and geriatric impairments and that a model incorporating these characteristics better predicts 30-day readmission. In Project 2, I will conduct a 2-year pilot prospective study t investigate the association of changes in cognition, mobility, and function between baseline and 1 week after hospitalization on subsequent 30-day readmission in 100 older adults in the NIH-funded SILVER-AMI study. I hypothesize that it will be feasible to leverage routine follow-up visits for geriatric assessment and that initial data will show that risk of readmission is higher n patients with continued delirium and limitation in mobility and function. In Project 3, I will explre mechanisms linking multimorbidity, geriatric impairments, and readmission through in-depth interviews of 15-25 older adults readmitted within 30 days of AMI. Interviews will explore the role of delirium, new mobility and functional limitations after hospitalization, and caregiver support o 30-day readmission. Study findings will improve risk-stratification, identify key targets for intervention, and demonstrate the feasibility of using routine post-discharge visits for geriatric assessment. This proposal will broaden my methodologic expertise to include analysis of administrative data linked to geriatric assessments, primary geriatric assessments via survey and physical performance measures, in-depth interviews, and mixed methods design. I will benefit from the tutelage of exceptional mentors with expertise in aging, heart disease, hospital readmission, and multiple research methodologies. I will also attain formal research training via a Master of Science in Public Health. The resulting skills and data will establish me as a strong candidate for an R01 designed to facilitate recovery after hospitalization and lower preventable readmissions among older adults.

Public Health Relevance

Multimorbidity and geriatric impairments are exceptionally common in older persons and are powerful predictors of adverse outcomes. Yet neither has been routinely incorporated into models predicting 30-day readmission or interventions aimed at reducing short-term rehospitalization even though 1 in 5 hospitalized older patients is readmitted within 30 days of discharge. This proposal on the role of multimorbidity, cognitive impairment, mobility limitation, and functional limitation in influencing the risk of 30-day readmission followng hospitalization for acute myocardial infarction will provide insight into the impact of common geriatric conditions during a period of increased vulnerability for many older persons and can improve patient outcomes by enhancing risk-stratification and identifying key targets for intervention.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Mentored Patient-Oriented Research Career Development Award (K23)
Project #
1K23AG048331-01
Application #
8769602
Study Section
Special Emphasis Panel (ZAG1)
Program Officer
Bhattacharyya, Partha
Project Start
2014-09-01
Project End
2019-06-30
Budget Start
2014-09-01
Budget End
2015-06-30
Support Year
1
Fiscal Year
2014
Total Cost
Indirect Cost
Name
Yale University
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
City
New Haven
State
CT
Country
United States
Zip Code
06510
Desai, Nihar R; Ross, Joseph S; Kwon, Ji Young et al. (2016) Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions. JAMA 316:2647-2656
Zheng, Xin; Curtis, Jeptha P; Hu, Shuang et al. (2016) Coronary Catheterization and Percutaneous Coronary Intervention in China: 10-Year Results From the China PEACE-Retrospective CathPCI Study. JAMA Intern Med 176:512-21
Zeitler, Emily P; Wang, Yongfei; Dharmarajan, Kumar et al. (2016) Outcomes 1 Year After Implantable Cardioverter-Defibrillator Lead Abandonment Versus Explantation for Unused or Malfunctioning Leads: A Report from the National Cardiovascular Data Registry. Circ Arrhythm Electrophysiol 9:
Dharmarajan, Kumar; Strait, Kelly M; Tinetti, Mary E et al. (2016) Treatment for Multiple Acute Cardiopulmonary Conditions in Older Adults Hospitalized with Pneumonia, Chronic Obstructive Pulmonary Disease, or Heart Failure. J Am Geriatr Soc 64:1574-82
Dharmarajan, Kumar; Chaudhry, Sarwat I (2016) New Approaches to Reduce Readmissions in Patients With Heart Failure. JAMA Intern Med 176:318-20
Dharmarajan, Kumar; Krumholz, Harlan M (2015) Risk after hospitalization: we have a lot to learn. J Hosp Med 10:135-6
Dharmarajan, Kumar (2015) Variation in care and outcome following myocardial infarction. BMJ 351:h4133
Dreyer, Rachel P; Ranasinghe, Isuru; Wang, Yongfei et al. (2015) Sex Differences in the Rate, Timing, and Principal Diagnoses of 30-Day Readmissions in Younger Patients with Acute Myocardial Infarction. Circulation 132:158-66
Al-Damluji, Mohammed Salim; Dharmarajan, Kumar; Zhang, Weiwei et al. (2015) Readmissions after carotid artery revascularization in the Medicare population. J Am Coll Cardiol 65:1398-408
Dharmarajan, Kumar; Krumholz, Harlan M (2015) Opportunities and challenges for reducing hospital revisits. Ann Intern Med 162:793-4

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