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Gonzalez-Jaramillo V, Arenas Ochoa LF, Saldarriaga C, Krikorian A, Vargas JJ, Gonzalez-Jaramillo N, Eychmüller S, Maessen M. The 'Surprise question' in heart failure: a prospective cohort study. BMJ Support Palliat Care 2024; 14:68-75. [PMID: 34404746 PMCID: PMC10894837 DOI: 10.1136/bmjspcare-2021-003143] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/24/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The Surprise Question (SQ) is a prognostic screening tool used to identify patients with limited life expectancy. We assessed the SQ's performance predicting 1-year mortality among patients in ambulatory heart failure (HF) clinics. We determined that the SQ's performance changes according to sex and other demographic (age) and clinical characteristics, mainly left ventricular ejection fraction (LVEF) and the New York Heart Association (NYHA) functional classifications. METHODS We conducted a prospective cohort study in two HF clinics. To assess the performance of the SQ in predicting 1-year mortality, we calculated the sensitivity, specificity, positive and negative likelihood ratios, and the positive and negative predictive values. To illustrate if the results of the SQ changes the probability that a patient dies within 1 year, we created Fagan's nomograms. We report the results from the overall sample and for subgroups according to sex, age, LVEF and NYHA functional class. RESULTS We observed that the SQ showed a sensitivity of 85% identifying ambulatory patients with HF who are in the last year of life. We determined that the SQ's performance predicting 1-year mortality was similar among women and men. The SQ performed better for patients aged under 70 years, for patients with reduced or mildly reduced ejection fraction, and for patients NYHA class III/IV. CONCLUSIONS We consider the tool an easy and fast first step to identify patients with HF who might benefit from an advance care planning discussion or a referral to palliative care due to limited life expectancy.
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Affiliation(s)
- Valentina Gonzalez-Jaramillo
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | | | - Clara Saldarriaga
- Cardiology, Clinica Cardio VID, Medellin, Colombia
- Cardiology, University of Antioquia, Medellin, Colombia
| | - Alicia Krikorian
- School of Health Sciences, Pontifical Bolivarian University, Medellin, Colombia
| | - John Jairo Vargas
- School of Health Sciences, Pontifical Bolivarian University, Medellin, Colombia
- Institute of Cancerology, Las Americas Clinic, Medellin, Colombia
| | - Nathalia Gonzalez-Jaramillo
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Maud Maessen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
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Ribeiro SCC, Arantes Lopes TA, Costa JVG, Rodrigues CG, Maia IWA, Soler LDM, Marchini JFM, Neto RAB, Souza HP, Alencar JCG. The Physician Surprise Question in the Emergency Department: prospective cohort study. BMJ Support Palliat Care 2024:spcare-2024-004797. [PMID: 38316516 DOI: 10.1136/spcare-2024-004797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVES This study aims to test the ability of the surprise question (SQ), when asked to emergency physicians (EPs), to predict in-hospital mortality among adults admitted to an emergency room (ER). METHODS This prospective cohort study at an academic medical centre included consecutive patients 18 years or older who received care in the ER and were subsequently admitted to the hospital from 20 April 2018 to 20 October 2018. EPs were required to answer the SQ for all patients who were being admitted to hospital. The primary outcome was in-hospital mortality. RESULTS The cohort included 725 adults (mean (SD) age, 60 (17) years, 51% men) from 58 128 emergency department (ED) visits. The mortality rates were 20.6% for 30-day all-cause in-hospital mortality and 23.6% for in-hospital mortality. The diagnostic test characteristics of the SQ have a sensitivity of 53.7% and specificity of 87.1%, and a relative risk of 4.02 (95% CI 3.15 to 5.13), p<0.01). The positive and negative predictive values were 57% and 86%, respectively; the positive likelihood ratio was 4.1 and negative likelihood ratio was 0.53; and the accuracy was 79.2%. CONCLUSIONS We found that asking the SQ to EPs may be a useful tool to identify patients in the ED with a high risk of in-hospital mortality.
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Affiliation(s)
| | | | - Jose Victor Gomes Costa
- Disciplina de Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Caio Godoy Rodrigues
- Disciplina de Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ian Ward Abdalla Maia
- Disciplina de Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lucas de Moraes Soler
- Disciplina de Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Heraldo Possolo Souza
- Disciplina de Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Júlio César Garcia Alencar
- Disciplina de Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Universidade de São Paulo Faculdade de Odontologia de Bauru, Bauru, Brazil
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Um YW, Jo YH, Kim HE, Kang SH, Han DK, Lee JH, Park I. The Prognostic Value of the Modified Surprise Question in Critically Ill Emergency Department Patients. J Palliat Care 2023:8258597231217947. [PMID: 38031344 DOI: 10.1177/08258597231217947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Objective: The initiation of palliative care (PC) in the emergency department (ED) is effective in improving the quality of life for seriously ill patients. This study aimed to evaluate the prognostic value of the modified surprise question (mSQ), "Would you be surprised if this patient died in the next 30 days?" as a trigger for initiating PC in critically ill ED patients. Methods: We conducted a prospective cohort study over a 6-month period in an ED, during which 22 emergency residents answered the mSQ for critically ill ED patients (Korean Triage and Acuity Scale 1 or 2). The primary outcome was the accuracy of the positive mSQ (negative response to the mSQ) in predicting 30-day mortality, and logistic regression analysis was performed to identify the prognostic factors. Results: A total of 300 patients were enrolled, and the positive mSQ group included 118 (39.3%) patients. The 30-day mortality rate of the cohort was 10.0%. The sensitivity, specificity, positive predictive value, and negative predictive value of the positive mSQ were 83.3%, 65.6%, 21.2%, and 97.3%, respectively, with a c-statistic of 0.74 and a positive likelihood ratio of 2.42. In a multivariable analysis controlling for clinically relevant variables, the odds ratio for 30-day mortality of the positive mSQ was 4.76 (95% confidence interval, 1.61-14.09; P = .005). Conclusions: The mSQ may be valuable for identifying critically ill ED patients with an increased risk of 30-day mortality. Therefore, it may be utilized as a trigger for PC consultation in the ED.
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Affiliation(s)
- Young Woo Um
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
| | - Hee Eun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Seung Hyun Kang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Dong Kwan Han
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Inwon Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
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Koyavatin S, Liu SW, Sri-On J. A comparison of palliative care and rapid emergency screening (P-CaRES) tool, broad and narrow criteria, and surprise questions to predict survival of older emergency department patients. BMC Palliat Care 2023; 22:81. [PMID: 37370078 DOI: 10.1186/s12904-023-01205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Palliative care is a form of medical care designed to enhance the quality of life of patients with life-threatening conditions. This study was conducted to compare the accuracy of predicted survival the 1 and 3-month survival rate of Broad and narrow criteria, Surprise questions (SQ), and Palliative Care and Rapid Emergency Screening (P-CaRES) after admission to the emergency department (ED). METHODS This prospective cohort study was conducted at an urban teaching hospital in Thailand. Patients aged ≥ 65 years admitted to the ED were classified according to their emergency severity index (ESI) (Level: 1-3). We collected data on SQ, P-CaRES, and broad and narrow criteria. A survival data of participants were collected at 1 and 3 months after admission to the ED. The survival rate was calculated using the Kaplan-Meier and log-rank tests. RESULTS A total of 269 patients completed the study. P-CaRES positive and P-CaRES negative patients had 1-month survival rates of 81% and 94.8%, respectively (P = 0.37), and at 3-month survival rates of 70.7% and 90.1%, respectively (P < 0.001). SQ (not surprised) had a 1-month survival rate of 79.3%, while SQ (surprised) had a 97% survival rate (P = 0.01), and SQ (not surprised) had a 75.4% survival rate at 3-months, while SQ (surprised) had a 96.3% survival rate (P = 0.01). Broad and narrow criteria that were positive and negative had 1-month survival rates of 88.1% and 92.5%, respectively (P = 0.71), while those that were positive and negative had 3-month survival rates of 78.6% and 87.2%, respectively (P = 0.19). The hazard ratio (HR) of SQ (not surprised) at 1 month was 3.22( 95%CI:1.16-8.89). The HR at 3 months of P-CaRES (positive) was 3.31 with a 95% confidence interval (CI): 1.74 - 6.27, while the HR for SQ (not surprise) was 7.33, 95% CI: 3.03-19.79; however, broad and narrow criteria had an HR of 1.78, 95% CI:0.84-3.77. CONCLUSIONS Among older adults who visited the ED, the SQ were good prognosis tools for predicting 1 and 3-month survival, and P-CaRES were good prognostic tools for predicting 3-month survival.
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Affiliation(s)
- Siripan Koyavatin
- Emergency department, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Shan Woo Liu
- Emergency department, Massachusetts General Hospital, Boston, USA
| | - Jiraporn Sri-On
- Emergency department, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
- Geriatric Emergency Medicine Unit. The Department of Emergency Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen road. Dusit, Bangkok, 10130, Thailand.
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DeGroot L, Pavlovic N, Perrin N, Gilotra NA, Dy SM, Davidson PM, Szanton SL, Saylor MA. Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure. J Pain Symptom Manage 2023; 65:500-509. [PMID: 36736499 PMCID: PMC10192105 DOI: 10.1016/j.jpainsymman.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 02/03/2023]
Abstract
CONTEXT Physical frailty is emerging as a potential "trigger" for palliative care (PC) consultation, but the PC needs of physically frail persons with heart failure (HF) in the outpatient setting have not been well described. OBJECTIVES This study describes the PC needs of community dwelling, physically frail persons with HF. METHODS We included persons with HF ≥50 years old who experienced ≥1 hospitalization in the prior year and excluded those with moderate/severe cognitive impairment, hospice patients, or non-English speaking persons. Measures included the FRAIL scale (0-5: 0 = robust, 1-2 = prefrail, 3-5 = frail) and the Integrated Palliative Outcome Scale (IPOS) (17 items, score 0-68; higher score = higher PC needs). Multiple linear regression tested the association between frailty group and palliative care needs. RESULTS Participants (N = 286) had a mean age of 68 (range 50-92) were majority male (63%) and White (68%) and averaged two hospitalizations annually. Most were physically frail (44%) or prefrail (41%). Mean PC needs (IPOS) score was 19.7 (range 0-58). On average, participants reported 5.86 (SD 4.28) PC needs affecting them moderately, severely, or overwhelmingly in the last week. Patient-perceived family/friend anxiety (58%) weakness/lack of energy (58%), and shortness of breath (47%) were the most prevalent needs. Frail participants had higher mean PC needs score (26) than prefrail (16, P < 0.001) or robust participants (11, P < 0.001). Frail participants experienced an average of 8.32 (SD 3.72) moderate/severe/overwhelming needs compared to prefrail (4.56, SD 3.77) and robust (2.39, SD 2.91) participants (P < 0.001). Frail participants reported higher prevalence of weakness/lack of energy (83%), shortness of breath (66%), and family/friend anxiety (69%) than prefrail (48%, 39%, 54%) or robust (13%, 14%, 35%) participants (P < 0.001). CONCLUSION Physically frail people with HF have higher unmet PC needs than those who are nonfrail. Implementing PC needs and frailty assessments may help identify vulnerable patients with unmet needs requiring further assessment and follow-up.
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Affiliation(s)
- Lyndsay DeGroot
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA.
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Johns Hopkins University School of Medicine (N.A.G), Baltimore, Maryland, USA
| | - Sydney M Dy
- Johns Hopkins University School of Public Health (S.M.D), Baltimore, Maryland, USA
| | | | - Sarah L Szanton
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Martha Abshire Saylor
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
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Sannemann L, Bach L, Hower KI, Ihle P, Keller K, Leikert C, Leminski C, Meixner A, Meyer I, Nordmeyer L, Peltzer S, Peter S, Werner B, Kuntz L, Pfaff H, Schulz-Nieswandt F, Albus C, Jessen F. Effects of a Primary Care-Based Intervention on the Identification and Management of Patients with Coronary Heart Disease and Mental or Cognitive Comorbidity-A Study Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105814. [PMID: 37239541 DOI: 10.3390/ijerph20105814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/27/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
Mental and cognitive disorders (MCD) negatively affect the incidence and prognosis of coronary heart disease (CHD). Medical guidelines recommend the appropriate management of comorbid MCD in patients with CHD, yet there is evidence that the implementation in primary care is not always adequate. We present the protocol for a pilot study that aims to develop a minimally invasive intervention and evaluate its feasibility in the primary care setting to improve the identification and management of comorbid MCD in patients with CHD. The study consists of two consecutive parts and will be carried out in Cologne, Germany. Part 1 comprises the development and tailoring of the intervention, which is guided by qualitative interviews with primary care physicians (PCPs, n = 10), patients with CHD and MCD and patient representatives (n = 10). Part II focuses on the implementation and evaluation of the intervention in n = 10 PCP offices. Changes in PCP behaviour will be analysed by comparing routine data in the practice management system six months before and six months after study participation. In addition, we will explore the influence of organisational characteristics and perform a socio-economic impact assessment. The outcomes of this mixed-method study will inform the feasibility of a PCP-based intervention to improve quality of care in patients with CHD and comorbid MCD.
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Affiliation(s)
- Lena Sannemann
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and Cologne University Hospital, University of Cologne, Kerpener Str. 62, 50924 Cologne, Germany
| | - Lisa Bach
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences, Faculty of Medicine and University Hospital Cologne, University of Cologne, Eupener Str. 129, 50933 Cologne, Germany
| | - Kira Isabel Hower
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences, Faculty of Medicine and University Hospital Cologne, University of Cologne, Eupener Str. 129, 50933 Cologne, Germany
| | - Peter Ihle
- PMV Research Group, Faculty of Medicine and Cologne University Hospital, University of Cologne, Herderstraße 52, 50931 Cologne, Germany
| | - Kai Keller
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences, Faculty of Medicine and University Hospital Cologne, University of Cologne, Eupener Str. 129, 50933 Cologne, Germany
| | - Charlotte Leikert
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine and Cologne University Hospital, University of Cologne, Weyertal 76, 50931 Cologne, Germany
| | - Christin Leminski
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences, Faculty of Medicine and University Hospital Cologne, University of Cologne, Eupener Str. 129, 50933 Cologne, Germany
| | - Adriana Meixner
- Department of Business Administration and Health Care Management, Faculty of Management, Economics and Social Sciences, University of Cologne, Albertus-Magnus-Platz, 50923 Cologne, Germany
| | - Ingo Meyer
- PMV Research Group, Faculty of Medicine and Cologne University Hospital, University of Cologne, Herderstraße 52, 50931 Cologne, Germany
| | - Laura Nordmeyer
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine and Cologne University Hospital, University of Cologne, Weyertal 76, 50931 Cologne, Germany
| | - Samia Peltzer
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine and Cologne University Hospital, University of Cologne, Weyertal 76, 50931 Cologne, Germany
| | - Sophie Peter
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences, Faculty of Medicine and University Hospital Cologne, University of Cologne, Eupener Str. 129, 50933 Cologne, Germany
- Chair of General Practice II and Patient-Centredness in Primary Care, Institute of General Practice and Primary Care, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58455 Witten, Germany
| | - Belinda Werner
- Institute of Sociology and Social Psychology (ISS), Faculty of Management, Economics and Social Sciences, University of Cologne, Albertus-Magnus-Platz, 50923 Cologne, Germany
| | - Ludwig Kuntz
- Department of Business Administration and Health Care Management, Faculty of Management, Economics and Social Sciences, University of Cologne, Albertus-Magnus-Platz, 50923 Cologne, Germany
- Centre for Health Services Research Cologne (ZVFK), University of Cologne, Eupener Str. 129, 50933 Cologne, Germany
| | - Holger Pfaff
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences, Faculty of Medicine and University Hospital Cologne, University of Cologne, Eupener Str. 129, 50933 Cologne, Germany
- Centre for Health Services Research Cologne (ZVFK), University of Cologne, Eupener Str. 129, 50933 Cologne, Germany
| | - Frank Schulz-Nieswandt
- Institute of Sociology and Social Psychology (ISS), Faculty of Management, Economics and Social Sciences, University of Cologne, Albertus-Magnus-Platz, 50923 Cologne, Germany
| | - Christian Albus
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine and Cologne University Hospital, University of Cologne, Weyertal 76, 50931 Cologne, Germany
| | - Frank Jessen
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and Cologne University Hospital, University of Cologne, Kerpener Str. 62, 50924 Cologne, Germany
- German Center for Neurodegenerative Diseases (DZNE), Venusberg-Campus 1/99, 53127 Bonn, Germany
- Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Joseph-Stelzmann-Str. 26, 50931 Cologne, Germany
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Aaronson EL, Kennedy M, Gillis-Crouch G, Zheng H, Jacobsen J, Ouchi K, Jackson V, Ritchie CS, Gioiella ME, Greenwald JL. Assessing the Acceptability and Feasibility of Leveraging Emergency Department Social Workers' Advanced Communication Skills to Assess Elderly Patients' Goals and Values. J Palliat Med 2023; 26:517-526. [PMID: 36576866 PMCID: PMC10325815 DOI: 10.1089/jpm.2022.0136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 12/29/2022] Open
Abstract
Background: The Emergency Department (ED) has increasingly been recognized as an important site of care for older adults with unmet palliative care needs. Despite this, no clear model of care delivery has emerged. Aim: To assess the acceptability and feasibility of a scripted palliative care communication intervention in the ED directed by social workers. We hypothesized that the intervention would be feasible, acceptable to patients and ED social workers, and that the collection of patient outcomes would be possible. Design: A prospective, unblinded, pilot randomized clinical trial of older adults with serious illness presenting to the ED. Patients were randomized to either receive a social worker-directed palliative care intervention (n-65), which consisted of a conversation focused on patients' goals, values, hopes and worries, or to usual care (n-52). The intervention was evaluated for feasibility and acceptability. Results: Of patients randomized to the intervention arm, 66% (43/65) completed a conversation with the social worker. Focus group feedback with the social workers further demonstrated the feasibility of these conversations. There was minimal (12%) loss to follow-up. Of the patients who received the intervention, the majority reported that they appreciated the social workers bringing up their goals for the future (77%), their social workers asking about their fears and worries (72%), and they liked the way the conversation was set up (81%). Social workers administered 95% of the conversation components. Conclusions: This pilot trial demonstrated the feasibility and acceptability of a social worker-directed, scripted palliative care communication intervention in a single urban, academic ED.
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Affiliation(s)
- Emily Loving Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace Gillis-Crouch
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hui Zheng
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Seel Ritchie
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Marie Elena Gioiella
- Department of Social Work, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey L. Greenwald
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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8
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Mirshahi A, Ghiasvandian S, Khoshavi M, Riahi SM, Khanipour-Kencha A, Bakitas M, Dionne-Odom JN, Wells R, Zakerimoghadam M. The feasibility and acceptability of an early tele-palliative care intervention to improve quality of life in heart failure patients in Iran: A protocol for a randomized controlled trial. Contemp Clin Trials Commun 2023; 33:101114. [PMID: 36993787 PMCID: PMC10041464 DOI: 10.1016/j.conctc.2023.101114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/27/2023] [Accepted: 03/10/2023] [Indexed: 03/28/2023] Open
Abstract
Background Heart failure (HF) has become a global health problem that has affected the quality of life of millions of people. One approach to improving patients’ quality of life (QoL) with chronic diseases such as HF is palliative care. In Iran, the bulk of palliative care research is directed to patients with cancer, with the primary focus on the physical aspect rather than the psychosocial and spiritual aspects of palliative care. To address this gap, this study aims to determine the feasibility and acceptability of this early tele-palliative care intervention to improve quality of life in heart failure patients in Iran. Methods The early tele-palliative care versus usual care study is designed as a single-centre, randomised, feasibility trial of 50 patients with heart failure aged 18 to 65 and clinician-determined New York Heart Association class II/III or American College of Cardiology stage B/C HF, recruited in Imam Khomeini Hospital Complex, Tehran, Iran. This intervention contains 6 weekly educational webinars and concurrent WhatsApp® group activities. Program feasibility and acceptability will be assessed by measuring the recruitment, attrition, and questionnaire completion rates; satisfaction and attitudes about the intervention will be measured via a telephone-based interviews. Secondary outcomes of Qol, mood status and number of emergency department visits will be measured with validated instruments. Participants in both groups will be followed up for 6 weeks, and the measures will be re-administered. Appropriate statistical tests will be used to analyse the data. Conclusion This is the first early tele-palliative care intervention designed for heart failure patients in Iran. The intervention has been developed by a multidisciplinary team of academic and clinical professionals with patient stakeholder input to create a rigorous and culturally responsive approach for palliative care delivery for heart failure patients in Iran. Trial registration IRCT registration number - IRCT20100725004443N29.
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Affiliation(s)
- Arvin Mirshahi
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- USERN Care (TUMS) Office, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Ghiasvandian
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Meysam Khoshavi
- Department of Cardiology, School of Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Riahi
- School of Medicine, Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Tehran, Iran
| | - Ali Khanipour-Kencha
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- USERN Care (TUMS) Office, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Marie Bakitas
- School of Nursing, and Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J. Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham (UAB) and UAB Center for Palliative and Supportive Care, USA
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Masoumeh Zakerimoghadam
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author. Departments of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq., Post Code: 14197-33171, Tehran, Iran.
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9
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Fürst P, Schultz T, Strang P. Specialized Palliative Care for Patients with Chronic Heart Failure at End of Life: Transfers, Emergency Department Visits, and Hospital Deaths. J Palliat Med 2022. [PMID: 36576786 DOI: 10.1089/jpm.2022.0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: Specialized palliative care (SPC) may contribute to improved quality of life in patients with life-limiting chronic heart failure (CHF). This study examined SPC and possible differences in the care process regarding emergency department (ED) visits, transfers, and place of death for severely ill patients with CHF. Materials and Methods: This retrospective observational registry study used the health care consumption data from the Stockholm Regional Council. Logistic regression analyses of age, sex, palliative care, comorbidities, and socioeconomic status were performed. Results: Of the 4322 individuals who died of heart failure between 2015 and 2019 and did not reside in a nursing home, 24% received SPC. Receiving SPC was associated with a lower odds ratio (OR) of ED visits (OR 0.24, p < 0.0001), unplanned transfers (OR 0.39, p < 0.0001), and emergency hospital as a place of death (OR 0.10, p < 0.0001). Furthermore, a better socioeconomic situation, younger age, and fewer comorbidities were associated with a lower OR of ED visits and transfers (p < 0.0001 to p = 0.013 in different comparisons). Multiple comorbidities (p < 0.0002) and younger age (p < 0.0001) were associated with a higher OR of emergency hospitals as a place of death. Conclusion: Approximately one-quarter of patients who died of heart failure received SPC. Receipt of SPC was associated with a significantly reduced number of ED visits, transfers between health care services, and risk of dying in emergency hospitals.
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Affiliation(s)
- Per Fürst
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Torbjörn Schultz
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Peter Strang
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Alizadeh F, Morell E, Hummel K, Wu Y, Wypij D, Matthew D, Esteso P, Moynihan K, Blume ED. The Surprise Question as a Trigger for Primary Palliative Care Interventions for Children with Advanced Heart Disease. Pediatr Cardiol 2022; 43:1822-1831. [PMID: 35503117 DOI: 10.1007/s00246-022-02919-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/18/2022] [Indexed: 11/25/2022]
Abstract
There is significant uncertainty in describing prognosis and a lack of reliable entry criteria for palliative care studies in children with advanced heart disease (AHD). This study evaluates the utility of the surprise question-"Would you be surprised if this child died within the next year?"-to predict one-year mortality in children with AHD and assess its utility as entry criteria for future trials. This is a prospective cohort study of physicians and nurses caring for children (1 month-19 years) with AHD hospitalized ≥ 7 days. AHD was defined as single ventricle physiology, pulmonary vein stenosis or pulmonary hypertension, or any cardiac diagnosis with signs of advanced disease. Primary physicians were asked the surprise question and medical record review was performed. Forty-nine physicians responded to the surprise question for 152 patients. Physicians responded "No, I would not be surprised if this patient died" for 54 (36%) patients, 20 (37%) of whom died within 1 year, predicting one-year mortality with 77% sensitivity, 73% specificity, 37% positive predictive value, and 94% negative predictive value. Patients who received a "No" response had an increased 1-year risk of death (hazard ratio 7.25, p < 0.001). Physician years of experience, subspecialty, and self-rated competency were not associated with the accuracy of the surprise question. The surprise question offers promise as a bedside screening tool to identify children with AHD at high risk for mortality and help physicians identify patients who may benefit from palliative care and advance care planning discussions.
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Affiliation(s)
- Faraz Alizadeh
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Emily Morell
- Division of Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, San Francisco, CA, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Kevin Hummel
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Yunhong Wu
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Danes Matthew
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Paul Esteso
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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11
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Kirkland SW, Yang EH, Garrido Clua M, Kruhlak M, Campbell S, Villa-Roel C, Rowe BH. Screening tools to identify patients with unmet palliative care needs in the emergency department: A systematic review. Acad Emerg Med 2022; 29:1229-1246. [PMID: 35344239 DOI: 10.1111/acem.14492] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/17/2022] [Accepted: 03/25/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This systematic review identified and assessed psychometric properties of the available screening tools to identify patients with unmet palliative care (PC) needs in the emergency department (ED). METHODS A comprehensive search of electronic databases and the gray literature was conducted. Two independent reviewers completed study screening and inclusion, data extraction, and quality assessment. A descriptive summary of the results was reported using median of medians and interquartile ranges (IQRs). RESULTS A total of 35 studies were included, involving the assessment of 14 unique screening tools. The most commonly used screening tool was the surprise question (SQ; n = 12 studies), followed by the Palliative Care and Rapid Emergency Screening (P-CaRES) tool (n = 8), and the screening for palliative and end-of-life care needs in the emergency department (SPEED) instrument (n = 4). Twelve of the included studies reported on the psychometric properties of the screening tools, of which eight of these studies assessed the performance of the SQ to predict patient mortality. Overall, the median sensitivity (63%, IQR 38%-78%) and specificity (75%, IQR 57%-84%) of the SQ to predict mortality at 1 or 12 months was moderate. While the median positive predictive value of the SQ was low (32%, IQR 16%-40%), the median negative predictive value was high (91%, IQR 88%-95%). Across the studies, the proportion of patients identified as having unmet PC based on the criteria of the screening tools ranged from 5% to 83%. CONCLUSIONS This review identified 14 unique screening tools used to identify adult patients with unmet PC needs in the ED. One screening tool, the SQ, was found to have moderate sensitivity and specificity to accurately predict future patient mortality. Additional research is needed to better understand the clinical value of this and the other available tools prior to their widespread implementation.
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Affiliation(s)
- Scott W Kirkland
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H Yang
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Miriam Garrido Clua
- Department of Orthopaedic Surgery, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Maureen Kruhlak
- School of Veterinary Medicine, St. George's University, West Indies, Grenada
| | - Sandra Campbell
- J.W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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12
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van Lummel EV, Ietswaard L, Zuithoff NP, Tjan DH, van Delden JJ. The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis. Palliat Med 2022; 36:1023-1046. [PMID: 35769037 PMCID: PMC10941345 DOI: 10.1177/02692163221099116] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The surprise question is widely used to identify patients nearing the last phase of life. Potential differences in accuracy between timeframe, patient subgroups and type of healthcare professionals answering the surprise question have been suggested. Recent studies might give new insights. AIM To determine the accuracy of the surprise question in predicting death, differentiating by timeframe, patient subgroup and by type of healthcare professional. DESIGN Systematic review and meta-analysis. DATA SOURCES Electronic databases PubMed, Embase, Cochrane Library, Scopus, Web of Science and CINAHL were searched from inception till 22nd January 2021. Studies were eligible if they used the surprise question prospectively and assessed mortality. Sensitivity, specificity, negative predictive value, positive predictive value and c-statistic were calculated. RESULTS Fifty-nine studies met the inclusion criteria, including 88.268 assessments. The meta-analysis resulted in an estimated sensitivity of 71.4% (95% CI [66.3-76.4]) and specificity of 74.0% (95% CI [69.3-78.6]). The negative predictive value varied from 98.0% (95% CI [97.7-98.3]) to 88.6% (95% CI [87.1-90.0]) with a mortality rate of 5% and 25% respectively. The positive predictive value varied from 12.6% (95% CI [11.0-14.2]) with a mortality rate of 5% to 47.8% (95% CI [44.2-51.3]) with a mortality rate of 25%. Seven studies provided detailed information on different healthcare professionals answering the surprise question. CONCLUSION We found overall reasonable test characteristics for the surprise question. Additionally, this study showed notable differences in performance within patient subgroups. However, we did not find an indication of notable differences between timeframe and healthcare professionals.
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Affiliation(s)
- Eline Vtj van Lummel
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Larissa Ietswaard
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolaas Pa Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dave Ht Tjan
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Johannes Jm van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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13
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Romero‐Correa M, Salamanca‐Bautista P, Bilbao‐González A, Quirós‐López R, Nieto‐Martín MD, Martín‐Jiménez ML, Morales‐Rull JL, Quiles‐García D, Gómez‐Gigirey A, Formiga F, Aramburu‐Bodas Ó, Arias‐Jiménez JL, Choucino‐Fernández T, Porto‐Pérez A, Piñeiro‐Parga P, Pedrosa‐Fraga C, Suárez‐Gil R, González‐Soler J, López‐Mato P, Latorre‐Díez A, Ferreira‐González L, Sánchez‐Cembellin M, Gallego‐Villalobos M, Rugeles‐Niño J, Rodríguez‐Avila E, González‐Franco A, Guerra‐Acebal C, Sebastián‐Leza A, Monte‐Armenteros J, Frutos‐Muñoyerro G, Clemente‐Sarasa C, Díez‐Manglano J, Josa‐Laorden C, Torres‐Courchoud I, Gómez‐Aguirre N, Jordana‐Camajuncosa R, Cajamarca‐Calva L, Torrente‐Jiménez I, Serrado‐Iglesias A, Ceresuela L, Salas‐Campos R, Delás‐Amat J, Brasé‐Arnau A, Petit‐Salas I, Romaní‐Costa V, Expósito‐López A, Sabbagh‐Fajardo C, Recio‐Iglesias J, Alemán‐Llansó C, Suriñach‐Caralt J, Trullás‐Vila J, Armengou‐Arxe A, García‐Torras S, Solé‐Felip C, Lacal‐Martínez A, Otero‐Soler M, Muela‐Molinero A, Carrera‐Izquierdo M, Arribas‐Arribas P, Inglada‐Galiana L, Ruiz ‐de Temiño Á, Silva‐Vázquez Á, Fuentes‐Pardo L, García‐García M, Piniella‐Ruiz E, Pérez‐Alves B, Gonzalo‐Pascua S, Marrero‐Francés J, Méndez‐Bailón M, Martín‐Sánchez F, Varas‐Mayoral M, Asenjo‐Martínez M, Yebra‐Yebra M, Sánchez‐Sauce B, Herreros B, Quesada‐Simón A, Vives‐Beltrán I, Álvarez‐Troncoso J, Martínez‐Marín L, Martínez PG, Mayorga ED, Moreno‐Palanco M, Soler‐Rangel L, Abellán‐Martínez J, Colás‐Herrera A, López‐Castellanos G, Ruíz‐Ortega R, Ruiz‐Barraza E, Montero‐Hernández E, Arévalo‐Lorido J, Carretero‐Gómez J, Calderón‐Jiménez P, Herrero‐Domingo A, Martín‐Barba S, Blázquez‐Encinar J, Jiménez‐Guardiola C, Cepeda‐Rodrigo J, Carrascosa‐García S, Llacer‐Iborra P, Moreno‐García M, Díez‐García L, Sánchez‐López P, Martínez‐Soriano M, Menor E, Montero‐Pérez‐Barquero M, Anguita‐Sánchez M, Sánchez‐Moruno M, Fuentes‐Espínola M, Zambrana‐García J, Guisado‐Espartero E, Mejías‐Real I, Alcalá‐Pedrajas J, Carrasco‐Sánchez F, Díaz‐Pérez C, Guzmán‐García M, Domingo‐Roa S, Cortés‐Rodríguez B, García‐Redecillas C, Martín‐Navarro R, Macías‐Ávila P, Antequera‐Martín‐Portugués I, Blanco‐Soto M, Flores‐Álvarez F, Aparicio‐Santos R, García‐Serrano R, Jiménez‐de‐Juan C, Ternero‐Vega J, Villalonga‐Comas M, Díaz‐Cañestro M, Asensio‐Rodríguez J, Gil‐Díaz A, Marrero‐Medina I, Puente‐Fernández A, Gudiño‐Aguirre D, Dávila‐Ramos M, Calderón E, Fernández‐Martínez J, Vázquez‐Rodríguez P, Conde‐Martel A, García‐García J, Páez‐Rubio I, López‐Reboiro M, Sánchez‐Sánchez C. The EPICTER score: a bedside and easy tool to predict mortality at 6 months in acute heart failure. ESC Heart Fail 2022. [PMCID: PMC9288794 DOI: 10.1002/ehf2.13924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims Estimating the prognosis in heart failure (HF) is important to decide when to refer to palliative care (PC). Our objective was to develop a tool to identify the probability of death within 6 months in patients admitted with acute HF. Methods and results A total of 2848 patients admitted with HF in 74 Spanish hospitals were prospectively included and followed for 6 months. Each factor independently associated with death in the derivation cohort (60% of the sample) was assigned a prognostic weight, and a risk score was calculated. The accuracy of the score was verified in the validation cohort. The characteristics of the population were as follows: advanced age (mean 78 years), equal representation of men and women, significant comorbidity, and predominance of HF with preserved ejection fraction. During follow‐up, 753 patients (26%) died. Seven independent predictors of mortality were identified: age, chronic obstructive pulmonary disease, cognitive impairment, New York Heart Association class III–IV, chronic kidney disease, estimated survival of the patient less than 6 months, and acceptance of a palliative approach by the family or the patient. The area under the ROC curve for 6 month death was 0.74 for the derivation and 0.68 for the validation cohort. The model showed good calibration (Hosmer and Lemeshow test, P value 0.11). The 6 month death rates in the score groups ranged from 6% (low risk) to 54% (very high risk). Conclusions The EPICTER score, developed from a prospective and unselected cohort, is a bedside and easy‐to‐use tool that could help to identify high‐risk patients requiring PC.
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Affiliation(s)
| | - Prado Salamanca‐Bautista
- Internal Medicine Department Hospital Universitario Virgen Macarena Seville Spain
- University of Seville Seville Spain
| | - Amaia Bilbao‐González
- Osakidetza Basque Health Service, Research Unit Basurto University Hospital Bilbao Spain
- Health Service Research Network on Chronic Diseases (REDISSEC) Barakaldo Spain
- Kronikgune Institute for Health Services Research Barakaldo Spain
| | | | | | | | | | - Dolores Quiles‐García
- Internal Medicine Department Hospital Universitario General de Valencia Valencia Spain
| | | | - Francesc Formiga
- Internal Medicine Department Hospital Universitari de Bellvitge Barcelona Spain
| | - Óscar Aramburu‐Bodas
- Internal Medicine Department Hospital Universitario Virgen Macarena Seville Spain
- University of Seville Seville Spain
| | - José Luis Arias‐Jiménez
- Internal Medicine Department Hospital Universitario Virgen Macarena Seville Spain
- University of Seville Seville Spain
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Blum M, Gelfman LP, McKendrick K, Pinney SP, Goldstein NE. Enhancing Palliative Care for Patients With Advanced Heart Failure Through Simple Prognostication Tools: A Comparison of the Surprise Question, the Number of Previous Heart Failure Hospitalizations, and the Seattle Heart Failure Model for Predicting 1-Year Survival. Front Cardiovasc Med 2022; 9:836237. [PMID: 35479267 PMCID: PMC9035562 DOI: 10.3389/fcvm.2022.836237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Score-based survival prediction in patients with advanced heart failure (HF) is complicated. Easy-to-use prognostication tools could inform clinical decision-making and palliative care delivery. Objective To compare the prognostic utility of the Seattle HF model (SHFM), the surprise question (SQ), and the number of HF hospitalizations (NoH) within the last 12 months for predicting 1-year survival in patients with advanced HF. Methods We retrospectively analyzed data from a cluster-randomized controlled trial of advanced HF patients, predominantly with reduced ejection fraction. Primary outcome was the prognostic discrimination of SHFM, SQ (“Would you be surprised if this patient were to die within 1 year?”) answered by HF cardiologists, and NoH, assessed by receiver operating characteristic (ROC) curve analysis. Optimal cut-offs were calculated using Youden’s index (SHFM: <86% predicted 1-year survival; NoH ≥ 2). Results Of 535 subjects, 82 (15.3%) had died after 1-year of follow-up. SHFM, SQ, and NoH yielded a similar area under the ROC curve [SHFM: 0.65 (0.60–0.71 95% CI); SQ: 0.58 (0.54–0.63 95% CI); NoH: 0.56 (0.50–0.62 95% CI)] and similar sensitivity [SHFM: 0.76 (0.65–0.84 95% CI); SQ: 0.84 (0.74–0.91 95% CI); NoH: 0.56 (0.45–0.67 95% CI)]. As compared to SHFM, SQ had lower specificity [SQ: 0.33 (0.28–0.37 95% CI) vs. SHFM: 0.55 (0.50–0.60 95% CI)] while NoH had similar specificity [0.56 (0.51–0.61 95% CI)]. SQ combined with NoH showed significantly higher specificity [0.68 (0.64–0.73 95% CI)]. Conclusion SQ and NoH yielded comparable utility to SHFM for 1-year survival prediction among advanced HF patients, are easy-to-use and could inform bedside decision-making.
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Affiliation(s)
- Moritz Blum
- Department of Internal Medicine and Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Moritz Blum,
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- James J. Peters Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center, Bronx, NY, United States
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sean P. Pinney
- Department of Medicine, University of Chicago Medicine, Chicago, IL, United States
| | - Nathan E. Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Méndez-Bailón M, Lorenzo-Villalba N, Romero-Correa M, Guisado-Espartero E, González-Soler J, Rugeles-Niño J, Sebastián-Leza A, Ceresuela-Eito L, Romaní-Costa V, Quesada-Simón A, Soler-Rangel L, Herrero-Domingo A, Díez-García L, Alcalá-Pedrajas J, Villalonga-Comas M, Andrès E, Gudiñ-Aguirre D, Formiga F, Aramburu-Bodas O, Arias-Jiménez J, Salamanca-Bautista P. Cancer Impacts Prognosis on Mortality in Patients with Acute Heart Failure: Analysis of the EPICTER Study. J Clin Med 2022; 11:jcm11030571. [PMID: 35160023 PMCID: PMC8836514 DOI: 10.3390/jcm11030571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 01/08/2023] Open
Abstract
Introduction: Heart failure (HF) and cancer are currently the leading causes of death worldwide, with an increasing incidence with age. Little is known about the treatment received and the prognosis of patients with acute HF and a prior cancer diagnosis. Objective: to determine the clinical characteristics, palliative treatment received, and prognostic impact of patients with acute HF and a history of solid tumor. Methods: The EPICTER study (“Epidemiological survey of advanced heart failure”) is a cross-sectional, multicenter project that consecutively collected patients admitted for acute HF in 74 Spanish hospitals. Patients were classified into two groups according to whether they met criteria for acute HF with and without solid cancer, and the groups were subsequently compared. A multivariable logistic regression analysis was conducted, using the forward stepwise method. A Kaplan–Meier survival analysis was performed to evaluate the impact of solid tumor on prognosis in patients with acute HF. Results: A total of 3127 patients were included, of which 394 patients (13%) had a prior diagnosis of some type of solid cancer. Patients with a history of cancer presented a greater frequency of weight loss at admission: 18% vs. 12% (p = 0.030). In the cancer group, functional impairment was noted more frequently: 43% vs. 35%, p = 0.039). Patients with a history of solid cancer more frequently presented with acute HF with preserved ejection fraction (65% vs. 58%, p = 0.048) than reduced or mildly reduced. In-hospital and 6-month follow-up mortality was 31% (110/357) in patients with solid cancer vs. 26% (637/2466), p = 0.046. Conclusion: Our investigation demonstrates that in-hospital mortality and mortality during 6-month follow-up in patients with acute HF were higher in those subjects with a history of concomitant solid tumor cancer diagnosis.
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Affiliation(s)
- Manuel Méndez-Bailón
- Hospital Clínico Universitario San Carlos, Instituto de Investigación Sanitaria (IdISSC), 28040 Madrid, Spain;
| | - Noel Lorenzo-Villalba
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France;
- Correspondence:
| | | | | | | | | | | | | | | | | | | | | | - Luis Díez-García
- Internal Medicine Department, Torrecárdenas Hospital, 04009 Almería, Spain;
| | - José Alcalá-Pedrajas
- Internal Medicine Department, Pozoblanco Hospital, 14400 Pozoblanco, Córdoba, Spain;
| | | | - Emmanuel Andrès
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France;
| | | | | | - Oscar Aramburu-Bodas
- Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain; (O.A.-B.); (J.A.-J.); (P.S.-B.)
| | - Jose Arias-Jiménez
- Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain; (O.A.-B.); (J.A.-J.); (P.S.-B.)
| | - Prado Salamanca-Bautista
- Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain; (O.A.-B.); (J.A.-J.); (P.S.-B.)
- Universidad de Sevilla, San Fernando, 4, 41004 Sevilla, Spain
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16
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White N, Oostendorp LJ, Vickerstaff V, Gerlach C, Engels Y, Maessen M, Tomlinson C, Wens J, Leysen B, Biasco G, Zambrano S, Eychmüller S, Avgerinou C, Chattat R, Ottoboni G, Veldhoven C, Stone P. An online international comparison of palliative care identification in primary care using the Surprise Question. Palliat Med 2022; 36:142-151. [PMID: 34596445 PMCID: PMC8796152 DOI: 10.1177/02692163211048340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Surprise Question ('Would I be surprised if this patient died within 12 months?') identifies patients in the last year of life. It is unclear if 'surprised' means the same for each clinician, and whether their responses are internally consistent. AIM To determine the consistency with which the Surprise Question is used. DESIGN A cross-sectional online study of participants located in Belgium, Germany, Italy, The Netherlands, Switzerland and UK. Participants completed 20 hypothetical patient summaries ('vignettes'). Primary outcome measure: continuous estimate of probability of death within 12 months (0% [certain survival]-100% [certain death]). A threshold (probability estimate above which Surprise Question responses were consistently 'no') and an inconsistency range (range of probability estimates where respondents vacillated between responses) were calculated. Univariable and multivariable linear regression explored differences in consistency. Trial registration: NCT03697213. SETTING/PARTICIPANTS Registered General Practitioners (GPs). Of the 307 GPs who started the study, 250 completed 15 or more vignettes. RESULTS Participants had a consistency threshold of 49.8% (SD 22.7) and inconsistency range of 17% (SD 22.4). Italy had a significantly higher threshold than other countries (p = 0.002). There was also a difference in threshold levels depending on age of clinician, for every yearly increase, participants had a higher threshold. There was no difference in inconsistency between countries (p = 0.53). CONCLUSIONS There is variation between clinicians regarding the use of the Surprise Question. Over half of GPs were not internally consistent in their responses to the Surprise Question. Future research with standardised terms and real patients is warranted.
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Affiliation(s)
- Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Linda Jm Oostendorp
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Primary Care and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Christina Gerlach
- Palliative Care Unit, Department of Oncology, Hematology and BMT, and Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Interdisciplinary Palliative Care Unit, Department of Hematology, Oncology, and Pneumology, University Medical Center, Mainz, Germany
| | - Yvonne Engels
- Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Maud Maessen
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Christopher Tomlinson
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Johan Wens
- Department Family Medicine and Population Health (FamPop), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Bert Leysen
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Guido Biasco
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna & Academy of the Sciences of Palliative Medicine, Bologna, Italy
| | - Sofia Zambrano
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Christina Avgerinou
- Primary Care and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Rabih Chattat
- Department of Psychology, University of Bologna, Bologna, Italy
| | | | - Carel Veldhoven
- Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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17
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Kirkland SW, Garrido Clua M, Kruhlak M, Villa-Roel C, Couperthwaite S, Yang EH, Elwi A, O’Neill B, Duggan S, Brisebois A, Rowe BH. Comparison of characteristics and management of emergency department presentations between patients with met and unmet palliative care needs. PLoS One 2021; 16:e0257501. [PMID: 34570790 PMCID: PMC8476017 DOI: 10.1371/journal.pone.0257501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/02/2021] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION This study examined emergency department (ED) presentations of patients with end of life (EOL) conditions and patients having met and unmet palliative care needs were compared. METHODS Presentations for EOL conditions were prospectively identified and screened for palliative care needs. Descriptive data were reported as proportions, means or medians. Bi-variable analysis for dichotomous and continuous variables were performed by chi-squared and T-tests (p≤0.01), respectively. A multivariable logistic regression model identified factors associated with having unmet palliative needs and reported adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS Overall, 663 presentations for EOL conditions were identified; 518 (78%) involved patients with unmet palliative care needs. Presentations by patients with unmet palliative needs were more likely to involve consultations (80% vs. 67%, p = 0.001) and result in hospitalization (69% vs. 51%, p<0.001) compared to patients whose palliative needs were met. Patients with unmet palliative care needs were more likely to have previous ED visits (73% unmet vs. 48% met; p<0.001). While medication, procedures, investigations and imaging ordering were high across all patients with EOL conditions, there were no significant differences between the groups. Consultations with palliative specialists in the ED (6% unmet vs. 1% met) and following discharge (29% unmet vs. 18% met) were similarly uncommon. Patients having two or more EOL conditions (aOR = 2.41; 95% CI: 1.16, 5.00), requiring hospitalization (aOR = 1.93; 95% CI: 1.30, 2.87), and dying during the ED visit (aOR = 2.15; 95% CI: 1.02, 4.53) were strongly associated with having unmet palliative care needs. CONCLUSIONS Most ED presentations for EOL conditions were made by patients with unmet palliative care needs, who were significantly more likely to require consultation, hospitalization, and to die. Referrals to palliative care services during and after the ED visit were infrequent, indicating important opportunities to promote these services.
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Affiliation(s)
- Scott W. Kirkland
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
| | | | - Maureen Kruhlak
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
| | | | - Esther H. Yang
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
| | - Adam Elwi
- Alberta Health Services, Edmonton, Alberta, Canada
| | | | - Shelley Duggan
- Grey Nun Hospital, Covenant Health, Edmonton, Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Brisebois
- Grey Nun Hospital, Covenant Health, Edmonton, Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
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18
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Gonzalez-Jaramillo V, Guyer J, Luethi N, Sobanski P, Zbinden R, Rodriguez E, Hunziker L, Eychmüller S, Maessen M. Validation of the German version of the needs assessment tool: progressive disease-heart failure. Health Qual Life Outcomes 2021; 19:214. [PMID: 34488787 PMCID: PMC8419951 DOI: 10.1186/s12955-021-01817-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/03/2021] [Indexed: 12/14/2022] Open
Abstract
Background The Needs Assessment Tool: Progressive Disease-Heart Failure (NAT: PD-HF) is a tool created to assess the needs of people living with heart failure and their informal caregivers to assist delivering care in a more comprehensive way that addresses actual needs that are unmet, and to improve quality of life. In this study, we aimed to (1) Translate the tool into German and culturally adapt it. (2) Assess internal consistency, inter-rater reliability, and test–retest reliability of the German NAT: PD-HF. (3) Evaluate whether and how patients and health care personnel understand the tool and its utility. (4) Assess the tool’s face validity, applicability, relevance, and acceptability among health care personnel. Methods Single-center validation study. The tool was translated from English into German using a forward–backward translation. To assess internal consistency, we used Cronbach´s alpha. To assess inter-rater reliability and test–retest reliability, we used Cohen´s kappa, and to assess validity we used face validity. Results The translated tool showed good internal consistency. Raters were in substantial agreement on a majority of the questions, and agreement was almost perfect for all the questions in the test–retest analysis. Face validity was rated high by health care personnel. Conclusion The German NAT: PD-HF is a reliable, valid, and internally consistent tool that is well accepted by both patients and health care personnel. However, it is important to keep in mind that effective use of the tool requires training of health care personnel. Supplementary Information The online version contains supplementary material available at 10.1186/s12955-021-01817-6.
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Affiliation(s)
- Valentina Gonzalez-Jaramillo
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. .,Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Jelena Guyer
- Department of General Surgery, Spital Emmental, Burgdorf, Switzerland.,Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Nora Luethi
- University Center for Palliative Care, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Piotr Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Spital Schwyz, Schwyz, Switzerland
| | - Rut Zbinden
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | | | - Lukas Hunziker
- Department of Cardiology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Center for Palliative Care, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Maud Maessen
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,University Center for Palliative Care, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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19
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Egídio de Sousa I, Pedroso A, Chambino B, Roldão M, Pinto F, Guerreiro R, Araújo I, Henriques C, Fonseca C. Palliative Care in Heart Failure: Challenging Prognostication. Cureus 2021; 13:e18301. [PMID: 34722076 PMCID: PMC8548045 DOI: 10.7759/cureus.18301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2021] [Indexed: 12/13/2022] Open
Abstract
Heart failure (HF) is a chronic progressive disease with high morbimortality and poor quality of life (QoL). Palliative care significantly improves clinical outcomes but few patients receive it, in part due to challenging decisions about prognosis. This retrospective study, included all patients consecutively discharged from an Acute Heart Failure Unit over a period of one year, aiming to assess the accuracy of the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in predicting mortality. Additionally, predictors of death at one and three years were explored using a multivariate regression model. The MAGGIC score was useful in predicting mortality, without significant difference between mortality observed at three-years follow-up compared with a mortality given by the score (p=0.115). Selected variables were statistically compared showing that poor functional status, high New York Heart Association (NYHA) at discharge, psychopharmacs use, and high creatininemia were associated with higher mortality (p<0.05). The multivariate regression model identified three predictors of one-year mortality: psychopharmacs baseline use (OR=4.110; p=0.014), angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) medication at discharge (OR=0.297; p=0.033), and higher admission's creatinine (OR=2.473; p=0.028). For three-year mortality outcome, two variables were strong independent predictors: psychopharmacs (OR=3.330; p=0.022) and medication with ACEI/ARB at discharge (OR=0.285; p=0.018). Models' adjustment was assessed through the receiver operating characteristic (ROC) curve. The best model was the one-year mortality (area under the curve, AUC 81%), corresponding to a good discrimination power. Despite prognostication, when setting goals of care an individualised patient-centred approach is imperative, based on the patient's objectives and needs. Risk factors related to poorer outcomes should be considered, in particular, higher NYHA at discharge which also represents symptom burden. Hospitalisation is an opportunity to optimize global care for heart failure patients including palliative care.
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Affiliation(s)
| | - Ana Pedroso
- Internal Medicine Department, Hospital São Francisco Xavier, Lisbon, PRT
| | - Beatriz Chambino
- Internal Medicine Department, Hospital São Francisco Xavier, Lisbon, PRT
| | - Marta Roldão
- Internal Medicine Department, Hospital São Francisco Xavier, Lisbon, PRT
| | - Fausto Pinto
- Internal Medicine Department, Hospital São Francisco Xavier, Lisbon, PRT
| | - Renato Guerreiro
- Internal Medicine Department, Hospital São Francisco Xavier, Lisbon, PRT
| | - Inês Araújo
- Heart Failure Clinic, Department of Internal Medicine, Hospital São Francisco Xavier, Lisbon, PRT
| | - Célia Henriques
- Heart Failure Clinic, Department of Internal Medicine, Hospital São Francisco Xavier, Lisbon, PRT
| | - Candida Fonseca
- Heart Failure Clinic, Department of Internal Medicine, Hospital São Francisco Xavier, Lisbon, PRT
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20
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Tripp D, Janis J, Jarrett B, Lucas FL, Strout TD, Han PKJ, Stumpf I, Hutchinson RN. How Well Does the Surprise Question Predict 1-year Mortality for Patients Admitted with COPD? J Gen Intern Med 2021; 36:2656-2662. [PMID: 33409886 PMCID: PMC8390592 DOI: 10.1007/s11606-020-06512-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/17/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP. OBJECTIVE To assess how well the SQ predicts mortality and prompts ACP for COPD patients. DESIGN Retrospective cohort study. SUBJECTS Patients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018. MAIN MEASURES Emergency department (ED) and inpatient clinicians answered, "Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?" The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document). KEY RESULTS The 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39-4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64-4.36). CONCLUSIONS The 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.
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Affiliation(s)
- Dana Tripp
- Tufts University School of Medicine, Boston, MA, USA
| | - Jaclyn Janis
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Benjamin Jarrett
- Division of Pulmonary Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Tania D Strout
- Tufts University School of Medicine, Boston, MA, USA.,Department of Emergency Medicine, Maine Medical Center, Portland, ME, USA
| | - Paul K J Han
- Tufts University School of Medicine, Boston, MA, USA.,Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Isabella Stumpf
- Tufts University School of Medicine, Boston, MA, USA.,Division of Palliative Medicine, Maine Medical Center, Portland, ME, USA
| | - Rebecca N Hutchinson
- Tufts University School of Medicine, Boston, MA, USA. .,Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA. .,Division of Palliative Medicine, Maine Medical Center, Portland, ME, USA.
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21
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Loffredo AJ, Chan GK, Wang DH, Goett R, Isaacs ED, Pearl R, Rosenberg M, Aberger K, Lamba S. United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department. Ann Emerg Med 2021; 78:658-669. [PMID: 34353647 DOI: 10.1016/j.annemergmed.2021.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.
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Affiliation(s)
- Anthony J Loffredo
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Garrett K Chan
- Department of Physiologic Nursing, University of California, San Francisco, CA
| | - David H Wang
- Division of Palliative Medicine, Scripps Health, San Diego, CA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Eric D Isaacs
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Rachel Pearl
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark Rosenberg
- Department of Emergency Medicine, St Joseph's Health, Paterson and Wayne, NJ
| | - Kate Aberger
- Division of Palliative Medicine and Geriatrics, St Joseph's Health, Paterson, NJ; Department of Emergency Medicine, Robert Wood Johnson University Hospital Somerset, Somerville, NJ
| | - Sangeeta Lamba
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
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22
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Ernecoff NC, Abdel-Kader K, Cai M, Yabes J, Shah N, Schell JO, Jhamb M. Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD. KIDNEY360 2021; 2:966-973. [PMID: 35373084 PMCID: PMC8791363 DOI: 10.34067/kid.0007062020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Background The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflows have slowed SQ implementation in practice. Objectives The aims of this study were: (1) to evaluate implementation outcomes after the use of electronic health record (EHR) decision support to automate the collection of the SQ; and (2) to assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits. Methods We developed and implemented a best practice alert (BPA) in the EHR to identify nephrology outpatients ≥60 years of age with an eGFR <30 ml/min per 1.73 m2. At appointment, the BPA prompted the physician to answer the SQ. We assessed the rate and timeliness of provider responses. We conducted a post-hoc open-ended survey to assess physician perceptions of SQ implementation. We assessed the SQ's prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses. Results Among 510 patients for whom the BPA triggered, 95 (19%) had the SQ completed by 16 physicians. Among those completed, nearly all (98%) were on appointment day, and 61 (64%) the first time the BPA fired. Providers answered "no" for 27 (28%) and "yes" for 68 (72%) patients. By 12 months, six (22%) "no" patients died; three (4%) "yes" patients died (hazard ratio [HR] 2.86, ref: yes, 95% CI, 1.06 to 7.69). About 35% of "no" patients and 32% of "yes" patients had a hospital encounter by 12 months (HR, 1.85, ref: yes, 95% CI, 0.93 to 3.69). Physicians noted (1) they had goals-of-care conversations unprompted; (2) EHR-based interventions alone for goals-of-care are ineffective; and (3) more robust engagement is necessary. Conclusions We successfully integrated the SQ into the EHR to aid in clinical practice. Additional implementation efforts are needed to encourage further integration of the SQ in clinical practice.
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Affiliation(s)
- Natalie C. Ernecoff
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University, Nashville, Tennessee
| | - Manqi Cai
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Yabes
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nirav Shah
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manisha Jhamb
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
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23
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Gelfman LP, Mather H, McKendrick K, Wong AY, Hutchinson MD, Lampert RJ, Lipman HI, Matlock DD, Swetz KM, Pinney SP, Morrison RS, Goldstein NE. Non-Concordance between Patient and Clinician Estimates of Prognosis in Advanced Heart Failure. J Card Fail 2021; 27:700-705. [PMID: 34088381 PMCID: PMC8186811 DOI: 10.1016/j.cardfail.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Despite efforts to enhance serious illness communication, patients with advanced heart failure (HF) lack prognostic understanding. OBJECTIVES To determine rate of concordance between HF patients' estimation of their prognosis and their physician's estimate of the patient's prognosis, and to compare patient characteristics associated with concordance. DESIGN Cross-sectional analysis of a cluster randomized controlled trial with 24-month follow-up and analysis completed on 09/01/2020. Patients were enrolled in inpatient and outpatient settings between September 2011 to February 2016 and data collection continued until the last quarter of 2017. SETTING Six teaching hospitals in the U.S. PARTICIPANTS Patients with advanced HF and implantable cardioverter defibrillators (ICDs) at high risk of death. Of 537 patients in the parent study, 407 had complete data for this analysis. INTERVENTION A multi-component communication intervention on conversations between HF clinicians and their patients regarding ICD deactivation and advance care planning. MAIN OUTCOME(S) AND MEASURE(S) Patient self-report of prognosis and physician response to the "surprise question" of 12-month prognosis. Patient-physician prognostic concordance (PPPC) measured in percentage agreement and kappa. Bivariate analyses of characteristics of patients with and without PPPC. RESULTS Among 407 patients (mean age 62.1 years, 29.5% female, 42.4% non-white), 300 (73.7%) dyads had non-PPPC; of which 252 (84.0%) reported a prognosis >1 year when their physician estimated <1 year. Only 107 (26.3%) had PPPC with prognosis of ≤ 1 year (n=20 patients) or > 1 year (n=87 patients); (Κ = -0.20, p = 1.0). Of those with physician estimated prognosis of < 1 year, non-PPPC was more likely among patients with lower symptom burden- number and severity (both p ≤.001), without completed advance directive (p=.001). Among those with physician prognosis estimate > 1 year, no patient characteristic was associated with PPPC or non-PPPC. CONCLUSIONS AND RELEVANCE Non-PPPC between HF patients and their physicians is high. HF patients are more optimistic than clinicians in estimating life expectancy. These data demonstrate there are opportunities to improve the quality of prognosis disclosure between patients with advanced HF and their physicians. Interventions to improve PPPC might include serious illness communication training.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY.
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, AZ
| | - Rachel J Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine
| | - Hannah I Lipman
- Hackensack Meridian Health, Hackensack, NJ; Hackensack Meridian School of Medicine
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center; Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, AL
| | - Sean P Pinney
- Division of Cardiology, UChicago Medicine, Chicago, IL
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
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24
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Ganz FD, Roeh K, Eid M, Hasin T, Harush C, Gotsman I. The need for palliative and support care services for heart failure patients in the community. Eur J Cardiovasc Nurs 2021; 20:138–146. [PMID: 33611419 DOI: 10.1177/1474515120951970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative care is a care option considered appropriate for those with heart failure, but is uncommon partially due to a lack of timely identification of those needing palliative care. A standard mechanism that triggers which heart failure patients should receive palliative care is not available. The Gold Standards Framework (GSF) identifies those needing palliative care but has not been investigated with heart failure patients. OBJECTIVES To describe palliative care provided in the community and determine whether the GSF can identify heart failure patients in need of palliative care. METHODS Descriptive study. A total of 252 heart failure patients in the community completed a demographic characteristics questionnaire, the Edmonton symptom assessment scale-revised and the Minnesota living with heart failure questionnaire. Clinical data were collected from the medical chart and the primary physician completed the GSF prognostic indicator guidance. RESULTS Participants had a mean age of 76.9 years (standard deviation 10.9), most at New York Heart Association level III (n=152, 60%). Fewer than half received pain medications (n=76, 30%), anxiolytics (n=35, 14%), antidepressants (n=64, 25%) or sleep medications (n=65, 26%). Eight patients spoke with a psychologist or psychologist (3%). One had an advanced directive and 16 (6%) had a record of discussions with their family caregivers. Three (1%) had end-of-life discussions with their healthcare providers. Most healthcare providers responded 'no' to the 'surprise question' (n=160, 63%). Sensitivity and specificity of the gold standards framework was poor. CONCLUSIONS Few community dwelling heart failure patients received most aspects of palliative care. The gold standards framework was not a good indicator of those who should receive palliative care.
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Affiliation(s)
- Freda DeKeyser Ganz
- Hadassah Hebrew University School of Nursing, Israel.,Jerusalem College of Technology, Israel
| | - Keshet Roeh
- Shaare Zedek Medical Center, Israel.,Hebrew University, Israel
| | - Muhammad Eid
- Hebrew University, Israel.,Clalit Health Services, Israel
| | - Tal Hasin
- Heart Failure Clinic, Shaare Zedek Medical Center, Israel
| | - Chen Harush
- Heart Failure Clinic, Shaare Zedek Medical Center, Israel
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Ament SM, Couwenberg IM, Boyne JJ, Kleijnen J, Stoffers HE, van den Beuken MH, Engels Y, Bellersen L, Janssen DJ. Tools to help healthcare professionals recognize palliative care needs in patients with advanced heart failure: A systematic review. Palliat Med 2021; 35:45-58. [PMID: 33054670 PMCID: PMC7797617 DOI: 10.1177/0269216320963941] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The delivery of palliative care interventions is not widely integrated in chronic heart failure care as the recognition of palliative care needs is perceived as difficult. Tools may facilitate healthcare professionals to identify patients with palliative care needs in advanced chronic heart failure. AIM To identify tools to help healthcare professionals recognize palliative care needs in patients with advanced chronic heart failure. DESIGN This systematic review was registered in the PROSPERO database (CRD42019131896). Evidence of tools' development, evaluation, feasibility, and implementation was sought and described. DATA SOURCES Electronic searches to identify references of tools published until June 2019 were conducted in MEDLINE, CINAHL, and EMBASE. Hand-searching of references and citations was undertaken. Based on the identified tools, a second electronic search until September 2019 was performed to check whether all evidence about these tools in the context of chronic heart failure was included. RESULTS Nineteen studies described a total of seven tools. The tools varied in purpose, intended user and properties. The tools have been validated to a limited extent in the context of chronic heart failure and palliative care. Different health care professionals applied the tools in various settings at different moments of the care process. Guidance and instruction about how to apply the tool revealed to be relevant but may be not enough for uptake. Spiritual care needs were perceived as difficult to assess. CONCLUSION Seven tools were identified which showed different and limited levels of validity in the context of palliative care and chronic heart failure.
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Affiliation(s)
- Stephanie Mc Ament
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Inge Me Couwenberg
- Department of Cardiology, Catharina Hospital, Eindhoven, North Brabant, The Netherlands
| | - Josiane Jj Boyne
- Department of Patient and Care, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Jos Kleijnen
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Kleijnen Systematic Reviews Ltd, York, UK
| | - Henri Ejh Stoffers
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Marieke Hj van den Beuken
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Louise Bellersen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Daisy Ja Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Department of Research and Education, Ciro, Horn, The Netherlands
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26
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Pham R, McQuade C, Somerfeld A, Blakowski S, Hickey GW. Palliative Care Consultation Affects How and Where Heart Failure Patients Die. Am J Hosp Palliat Care 2020; 38:807-811. [PMID: 33016083 DOI: 10.1177/1049909120963565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Determine the role of palliative care on terminal code status and setting of death for those with heart failure. BACKGROUND Although palliative care consultation (PCC) has increased for many conditions, PCC has not increased in those with cardiovascular disease. While it has been shown that the majority of those with heart failure die in medical facilities, the impact of PCC on terminal code status and setting of death requires further analysis. METHODS Patients admitted with heart failure between 2014-2015 at an academic VA Healthcare System were reviewed. Primary outcome was terminal code status. Secondary outcomes included setting of death, hospice utilization, and mortality scores. Student t-testing and Chi-square testing were performed where appropriate. RESULTS 334 patients were admitted with heart failure and had a median follow up time of 4.3 years. 196 patients died, with 122 (62%) receiving PCC and 74 (38%) without PCC. Patients were more likely to have terminal code statuses of comfort measures with PCC (OR = 4.6, p = 0.002), and less likely to be full code (OR = 0.09, p < 0.001). 146 patients had documented settings of death and were more likely to receive hospice services with PCC (OR 6.76, p < 0.001). A patient's chance of dying at home was not increased with PCC (OR 0.49, p = 0.07), but they were more likely to die with inpatient hospice (OR = 17.03; p < 0.001). CONCLUSION Heart failure patients who received PCC are more likely to die with more defined care preferences and with hospice services. This does not translate to dying at home.
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Affiliation(s)
- Richard Pham
- Division of Cardiology, Department of Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Casey McQuade
- Division of Cardiology, Department of Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alex Somerfeld
- Division of Cardiology, Department of Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sandra Blakowski
- Department of Medicine, 6595Veterans Health Administration Pittsburgh Health System, Pittsburgh, PA, USA
| | - Gavin W Hickey
- Division of Cardiology, Department of Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Wang DH, Heidt R. Emergency Department Admission Triggers for Palliative Consultation May Decrease Length of Stay and Costs. J Palliat Med 2020; 24:554-560. [PMID: 32897797 DOI: 10.1089/jpm.2020.0082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Emergency department (ED) initiated palliative consultation impacts downstream care utilization. Various admission consult triggers have been proposed without clear best practice or outcomes. Objective: This 18-month single-center study evaluated the clinical, operational, and financial impact of simplified admission triggers for ED-initiated palliative consults as compared to downstream Floor and intensive care unit (ICU) palliative consults initiated per usual practice. Methods: We distilled ED admission triggers into three criteria to ensure bedside actionability and sustainability: (1) end-stage illness, (2) functional limitation, and (3) clinician would not be surprised if the patient died this hospitalization. Eligible patients met all criteria, and received consultation within 24 hours of admission. We compared ED-initiated consults against Floor and ICU consults from March 1, 2018, to September 30, 2019, with matched cohort analysis to evaluate financial outcomes. Results: While overall palliative consult volume remained intentionally steady, the proportion of ED-initiated consults significantly increased (7% vs. 19%, p < 0.001). ED consistently comprised 15-25% of all monthly palliative consults. Compared with Floor, ED had similar ED length of stay (LOS) and inpatient mortality. Among live discharges, ED were more likely to be referred to hospice than Floor (59% vs. 47%, p = 0.24) or ICU (59% vs. 34%, p = 0.02). In a matched cohort analysis, ED demonstrated median cost avoidance of $9,082 per patient versus Floor ($5,578 vs. $14,660, p < 0.001) and $15,138 per patient versus ICU ($5,578 vs. $20,716, p < 0.001). ED had significantly shorter median LOS before consult than Floor (0 vs. 3 days, p < 0.001) or ICU (0 vs. 3 days, p < 0.001), which did not differ between live discharges or inpatient deaths. Overall hospital LOS was disproportionately shorter for ED, with a net difference-in-differences of 1-3.5 days compared to Floor and ICU. Conclusions: Simple ED admission triggers to expedite palliative engagement are associated with a 50-75% reduction in both hospital LOS and costs when compared against usual palliative consultation practice. ED initiation reduces both lead time before consultation and subsequent downstream hospitalization length.
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Affiliation(s)
- David H Wang
- Division of Palliative Medicine, Scripps Health, San Diego, California, USA
| | - Ryan Heidt
- Division of Palliative Medicine, Scripps Health, San Diego, California, USA
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Verhoef MJ, de Nijs EJM, Fiocco M, Heringhaus C, Horeweg N, van der Linden YM. Surprise Question and Performance Status Indicate Urgency of Palliative Care Needs in Patients with Advanced Cancer at the Emergency Department: An Observational Cohort Study. J Palliat Med 2019; 23:801-808. [PMID: 31880489 DOI: 10.1089/jpm.2019.0413] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The surprise question (SQ), "Would I be surprised if this patient died within one year?", is a simple instrument to identify patients with palliative care needs. The SQ-performance has not been evaluated in patients with advanced cancer visiting the emergency department (ED). Objective: To evaluate SQ's test characteristics and predictive value in patients with advanced cancer visiting the ED. Design: Observational cohort study. Setting: Patients >18 years with advanced cancer in the palliative phase visiting the ED of an academic medical center. Methods: Attending physicians answered the SQ (not surprised [NS] or surprised [S]) and estimated Eastern Cooperative Oncology Group (ECOG)-performance status. Disease, visit, and follow-up characteristics were retrospectively collected from charts. SQ's sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and Harrell's c-index were calculated. Prognostic values of SQ and other variables were assessed by using Cox proportional hazards models. Results: Two-hundred-and-forty-five patients were included (203 NS [83%] and 42 S [17%]), median age 62 years, 48% male. Follow-up on overall survival was updated until February 2019. At ED entry, NS-patients had worse ECOG-performance and more symptoms. At study closure, 233 patients had died (95%). Median survival was three months for NS-patients (interquartile [IQ]-range: 1-8); nine months for S-patients (IQ-range: 3-28) (p < 0.0001). SQ-performance for one-year mortality: sensitivity 89%, specificity 40%, PPV 85%, NPV 50%, c-index 0.56, and hazard ratio 2.1 for approaching death. ECOG 3-4 predicted death in NS-patients; addition to the SQ improved c-index (0.65); sensitivity (40%), specificity (92%), PPV (95%), and NPV (29%). Conclusions: At the ED, the SQ plus ECOG 3-4 helps identifying patients with advanced cancer and a limited life expectancy. Its use supports initiating appropriate care related to urgency of palliative care needs.
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Affiliation(s)
- Mary-Joanne Verhoef
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Ellen J M de Nijs
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Marta Fiocco
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.,Mathematical Institute, Leiden University, Leiden, the Netherlands
| | - Christian Heringhaus
- Department of Emergency Medicine and Leiden University Medical Center, Leiden, the Netherlands
| | - Nanda Horeweg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvette M van der Linden
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
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29
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Wang DH, Kuntz J, Aberger K, DeSandre P. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients in the Emergency Department. J Palliat Med 2019; 22:1597-1602. [DOI: 10.1089/jpm.2019.0251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David H. Wang
- Division of Palliative Medicine, Scripps Health, San Diego, California
| | - Joanne Kuntz
- Department of Emergency Medicine and Emory University School of Medicine, Atlanta, Georgia
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kate Aberger
- Division of Palliative Medicine and Geriatrics, St. Joseph's Health, Paterson, New Jersey
| | - Paul DeSandre
- Department of Emergency Medicine and Emory University School of Medicine, Atlanta, Georgia
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
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