Trends and Disparities in Palliative Care Encounters in Acute Heart Failure Admissions; Insight From National Inpatient Sample

Naming racism as a root cause of inequities in palliative care research: a scoping review

BACKGROUND

Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist.

OBJECTIVE

To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings.

METHODS

Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results.

RESULTS

We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common.

CONCLUSION

While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

Palliative Care Across the Spectrum of Heart Failure

Persons with heart failure (HF) often suffer from poor symptom control, decreased quality of life, and poor communication with their health care providers. These needs are particularly acute in advanced HF, a leading cause of death in the United States. Palliative care, when offered alongside HF disease management, offers improved symptom control, quality of life, communication, and caregiver satisfaction as well as reduced caregiver anxiety. The dynamic nature of the clinical trajectory of HF presents distinct symptom patterns, changing functional status, and uncertainty, which requires an adaptive, dynamic model of palliative care delivery. Due to a limited specialty-trained palliative care workforce, patients and their caregivers often cannot access these benefits, especially in the community. To meet these needs, new models are required that are better informed by high-quality data, engage a range of health care providers in primary palliative care principles, and have clear triggers for specialty palliative care engagement, with specific palliative interventions tailored to patient's illness trajectory and changing needs.

Trends in Specialty Palliative Care Service Utilization and In-Hospital Outcomes for Patients With Amyotrophic Lateral Sclerosis

Background: Hospitalized people with amyotrophic lateral sclerosis (ALS) may benefit from specialty palliative care services (sPCS). Objective: To describe access to in-hospital sPCS for people with ALS (pALS). Methods: We compared years 2010-2011 to 2018-2019, and conducted trend analyses of sPCS from 2010 to 2019 stratified by race. Results: Of 103,193 pALS admitted during the study period, 13,885 (13.4%) received sPCS. Rates of sPCS increased over time (2010-2011: 8.9% vs. 2018-2019: 16.6%; p < 0.01). From 2010 to 2019, there was an increase in sPCS (p-trend<0.01) for all studied racial groups. Conclusions: Access to palliative care has increased over time for pALS admitted to hospitals in the United States.

Palliative care in the cardiovascular intensive care unit: A systematic review of current literature

BACKGROUND

There has been an evolution in the disease severity and complexity of patients presenting to the cardiac intensive care unit (CICU). There are limited data evaluating the role of palliative care in contemporary CICU practice.

METHODS

PubMed Central, CINAHL, EMBASE, Medline, Cochrane Library, Scopus, and Web of Science databases were evaluated for studies on palliative care in adults (≥18 years) admitted with acute cardiovascular conditions - acute myocardial infarction, cardiogenic shock, cardiac arrest, advanced heart failure, post-cardiac surgery, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and pulmonary embolism - admitted to the CICU, coronary care unit or cardiovascular intensive care unit from 1/1/2000 to 8/8/2022. The primary outcome of interest was the utilization of palliative care services. Secondary outcomes of included studies were also addressed. Meta-analysis was not performed due to heterogeneity.

RESULTS

Of 5711 citations, 30 studies were included. All studies were published in the last seven years and 90 % originated in the United States. Twenty-seven studies (90 %) were retrospective analyses, with a majority from the National Inpatient Sample database. Heart failure was the most frequent diagnosis (47 %), and in-hospital mortality was reported in 67 % of studies. There was heterogeneity in the timing, frequency, and background of the care team that determined palliative care consultation. In two randomized trials, there appeared to be improvement in quality of life without an impact on mortality.

CONCLUSIONS

Despite the growing recognition of the role of palliative care, there are limited data on palliative care consultation in the CICU.

Exploring Heart Failure Mortality Trends and Disparities in Women: A Retrospective Cohort Analysis

Heart failure (HF) remains a significant cause of morbidity and mortality in women. Population-level analyses shed light on existing disparities and promote targeted interventions. We evaluated HF-related mortality data in women in the United States to identify disparities based on race/ethnicity, urbanization level, and geographic region. We conducted a retrospective cohort analysis utilizing the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database to identify HF-related mortality in the death files from 1999 to 2020. Age-adjusted HF mortality rates were standardized to the 2000 US population. We fit log-linear regression models to analyze mortality trends. Age-adjusted HF mortality rates in women have decreased significantly over time, from 97.95 in 1999 to 89.19 in 2020. Mortality mainly downtrended from 1999 to 2012, followed by a significant increase from 2012 to 2020. Our findings revealed disparities in mortality rates based on race and ethnicity, with the most affected population being non-Hispanic Black (age-adjusted mortality rates [AAMR] 90.36), followed by non-Hispanic White (AAMR 83.25), American Indian/Alaska Native (AAMR 64.27), and Asian/Pacific Islander populations (AAMR 37.46). We also observed that nonmetropolitan (AAMR 103.36) and Midwestern (AAMR 90.45) regions had higher age-adjusted mortality rates compared with metropolitan (AAMR 78.43) regions and other US census regions. In conclusion, significant differences in HF mortality rates were observed based on race/ethnicity, urbanization level, and geographic region. Disparities in HF outcomes persist and efforts to reduce HF-related mortality rates should focus on targeted interventions that address social determinants of health, including access to care and socioeconomic status.

Achieving Health Equity in the Care of Patients with Heart Failure

PURPOSE OF REVIEW

To discuss the prevailing racial and ethnic disparities in heart failure (HF) care by identifying barriers to equitable care and proposing solutions for achieving equitable outcomes.

RECENT FINDINGS

Throughout the entire spectrum of HF care, from prevention to implementation of guideline-directed medical therapy and advanced interventions, racial and ethnic disparities exist. Factors such as differential distribution of risk factors, poor access to care, inadequate representation in clinical trials, and discrimination from healthcare clinicians, among others, contribute to these disparities. Recent data suggests that despite improvements, disparities prevail in several aspects of HF care, hindering our progress towards equity in HF care. This review highlights the urgent need to address racial and ethnic disparities in HF care, emphasizing the importance of a multifaceted approach involving policy changes, quality improvement strategies, targeted interventions, and intentional community engagement. Our proposed framework was derived from existing research and emphasizes integrating equity into routine quality improvement efforts, tailoring interventions to specific populations, and advocating for policy transformation. By acknowledging these disparities, implementing evidence-based strategies, and fostering collaborative efforts, the HF community can strive to reduce disparities and achieve equity in HF care.

Palliative care provision for people living with heart failure: The Geneva model

As life expectancy rises and the survival rate after acute cardiovascular events improves, the number of people living and dying with chronic heart failure is increasing. People suffering from chronic ischemic and non-ischemic heart disease may experience a significant limitation of their quality of life which can be addressed by palliative care. Although international guidelines recommend the implementation of integrated palliative care for patients with heart failure, models of care are scarce and are often limited to patients at the end of life. In this paper, we describe the implementation of a model designed to improve the early integration of palliative care for patients with heart failure. This model has enabled patients to access palliative care when they normally would not have and given them the opportunity to plan their care in line with their values and preferences. However, the effectiveness of this interdisciplinary model of care on patients' quality of life and symptom burden still requires evaluation.

Special Considerations in the Care of Women With Advanced Heart Failure

Advanced heart failure (AHF) is associated with increased morbidity and mortality, and greater healthcare utilization. Recognition requires a thorough clinical assessment and appropriate risk stratification. There are persisting inequities in the allocation of AHF therapies. Women are less likely to be referred for evaluation of candidacy for heart transplantation or left ventricular assist device despite facing a higher risk of AHF-related mortality. Sex-specific risk factors influence progression to advanced disease and should be considered when evaluating women for advanced therapies. The purpose of this review is to discuss the role of sex hormones on the pathophysiology of AHF, describe the clinical presentation, diagnostic evaluation and definitive therapies of AHF in women with special attention to pregnancy, lactation, contraception and menopause. Future studies are needed to address areas of equipoise in the care of women with AHF.

Sinais e sintomas de pacientes com insuficiência cardíaca em cuidados paliativos: revisão de escopo

RESUMO Objetivo Mapear a produção de conhecimento acerca dos sinais e sintomas de pacientes com insuficiência cardíaca em cuidados paliativos. Método Revisão de escopo conduzida de acordo com a metodologia JBI e com a redação guiada pelo Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist. A busca foi realizada em setembro de 2021 por dois revisores independentes nas bases de dados referenciais e em portais de informação e de literatura cinzenta, utilizando majoritariamente os descritores “heart failure”, “signs and symptoms” e “palliative care”, com o operador booleano “and”, sem recorte temporal. Resultados Foram incluídos 34 artigos publicados entre 2001 e 2021, provenientes de revistas nacionais e internacionais, sendo 21 publicados nos Estados Unidos da América. Por meio desses artigos, foi possível mapear 93 sinais e sintomas, sendo que os mais frequentes foram dor, dispneia, fadiga, náusea e depressão. Conclusão Implicações para a prática esta revisão de escopo produziu um mapa da produção científica sobre os sinais e sintomas de insuficiência cardíaca em cuidados paliativos. O conhecimento dos sinais e sintomas auxilia os profissionais da saúde no desenvolvimento de técnicas e tecnologias para avaliar a severidade da insuficiência cardíaca, planejar intervenções paliativas e avaliar os seus resultados.

Racial and ethnic disparities in heart failure: current state and future directions

PURPOSE OF REVIEW

This review discusses the current state of racial and ethnic inequities in heart failure burden, outcomes, and management. This review also frames considerations for bridging disparities to optimize quality heart failure care across diverse communities.

RECENT FINDINGS

Treatment options for heart failure have diversified and overall heart failure survival has improved with the advent of effective pharmacologic and nonpharmacologic therapies. With increased recognition, some racial/ethnic disparity gaps have narrowed whereas others in heart failure outcomes, utilization of therapies, and advanced therapy access persist or worsen.

SUMMARY

Racial and ethnic minorities have the highest incidence, prevalence, and hospitalization rates from heart failure. In spite of improved therapies and overall survival, the mortality disparity gap in African American patients has widened over time. Racial/ethnic inequities in access to cardiovascular care, utilization of efficacious guideline-directed heart failure therapies, and allocation of advanced therapies may contribute to disparate outcomes. Strategic and earnest interventions considering social and structural determinants of health are critically needed to bridge racial/ethnic disparities, increase dissemination, and implementation of preventive and therapeutic measures, and collectively improve the health and longevity of patients with heart failure.

Palliative Care for People Living With Heart Disease-Does Sex Make a Difference?

The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.