Collaborative palliative care for advanced heart failure: outcomes and costs from the 'Better Together' pilot study

Palliative Care Education in Cardiovascular Disease Fellowships: A National Survey of Program Directors

BACKGROUND

Palliative care (PC) is an essential component of high-quality care for people with cardiovascular disease (CVD). However, little is known about the current state of PC education in CVD training, including attitudes toward integration of PC into training and implementation of PC by the program's leadership.

METHODS

We developed a nationwide, cross-sectional survey that queried education approaches, perspectives and barriers to PC education in general CVD fellowship training. The survey was distributed to 392 members of the American College of Cardiology Program Director (PD) listserv, representing 290 general CVD fellowships between 1/2023 and 4/2023. We performed descriptive and ꭕ2 analyses of survey data.

RESULTS

Of the program's representatives, 56 completed the survey (response rate = 19.3%). Respondents identified themselves as current PDs (89%), associate PDs (8.9%) or former PDs (1.8%), representing a diverse range of program sizes and types and regions of the country. Respondents reported the use of informal bedside teaching (88%), formal didactics (59%), online or self-paced modules (13%), in-person simulation (11%), and clinical rotations (16%) to teach PC content. Most programs covered PC topics at least annually, although there was variability by topic. We found no associations between program demographics and type or frequency of PC education. Most respondents reported dissatisfaction with the quantity (62%) or quality (59%) of the PC education provided. Barriers to PC education included an overabundance of other content to cover (36%) and perceived lack of fellow (20%) or faculty (18%) interest. Comments demonstrated the importance of PC education in fellowship, the lack of a requirement to provide PC education, difficulty in covering all topics, and suggestions of how PC skills should be taught.

CONCLUSIONS

In a national survey of CVD educational leadership concerning approaches to PC education in CVD training, respondents highlighted both challenges to implementation of formal PC curricula in cardiology training and opportunities for comprehensive PC education.

Palliative Care for Patients With Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) has become the leading form of heart failure worldwide, particularly among elderly patient populations. HFpEF is associated with significant morbidity and mortality that may benefit from incorporation of palliative care (PC). Patients with HFpEF have similarly high mortality rates to patients with heart failure with reduced ejection fraction. PC trials for heart failure have shown improvement in quality of life, quality of death, and health care utilization, although most trials defined heart failure clinically without differentiating between HFpEF and heart failure with reduced ejection fraction. As such, the timing and role of PC for HFpEF care remains uncertain, and PC referral rates for HFpEF are very low despite potential improvements in important patient-centered outcomes. Specific barriers to referral include limited data, prognostic uncertainty, provider misconceptions about PC, inadequate specialty PC workforce, complexities of treating multimorbidity, and limited home care options for patients with heart failure. While there are many barriers to integration of PC into HFpEF care, there are multiple potential benefits to patients with HFpEF throughout their disease course. As this population continues to grow, targeted efforts to study and implement PC interventions are needed to improve patient quality of life and death.

Expanding the Paradigm for Cardiovascular Palliative Care

Cardiovascular disease (CVD) is the leading cause of death worldwide. Despite medical advances, patients with CVD experience high morbidity and mortality rates, affecting their quality of life and death. Among CVD conditions, palliative care has been studied mostly in patients with heart failure, where palliative care interventions have been associated with improvements in patient-centered outcomes, including quality of life, end-of-life care, and health care use. Although palliative care is now incorporated into the American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines for heart failure, the role of palliative care for non-heart failure CVD remains uncertain. Across all causes of CVD, palliative care can play an important role in all domains of CVD care from initial diagnosis to terminal care. In addition to general cardiovascular palliative care practices applicable to all areas, disease-specific palliative care needs may warrant individualized palliative care models. In this review, we discuss the role of cardiovascular palliative care for ischemic heart disease, valvular disease, arrhythmias, peripheral artery disease, and adult congenital heart disease. Although there are multiple barriers to cardiovascular palliative care, we recommend a framework for studying and developing cardiovascular palliative care models to improve patient-centered goal-concordant care for this underserved patient population.

Effects of a home-based palliative heart failure program on quality of life among the elderly: a clinical trial study

INTRODUCTION

One of the frequent issues that lowers elderly people's quality of life is chronic heart failure, a progressive and life-limiting disease. The purpose of this study was to evaluate the effects of home-based palliative care (HBPC) on the quality of life of elderly patients with heart failure who received discharge orders from hospitals affiliated with Kerman University of Medical Sciences in 2022.

METHODS

One hundred heart failure patients were divided into two intervention and control groups for this randomized clinical trial study. The patients were then given the pre-test questionnaires, such as the demographic questionnaire and the Quality of Life Index (QLI) by Ferrans and Powers. The intervention group was given the home care plan. To measure the quality of life one month after the intervention, the quality of life questionnaire was lastly filled out by both groups following the last care session. Software called SPSS 22 was used to enter and analyze the patient data.

RESULTS

The mean age for the elderly in the intervention and in the control groups were 69.46 ± 11.61 and 66.14 ± 12.09 years, respectively. The palliative care program at home made a statistically significant difference in the quality of life and all of its components in the elderly with heart failure in the intervention group immediately after the intervention and one month after the intervention compared to before (P < 0.001). As a result, its scores improved compared to the stage before the intervention. Additionally, a significant difference between the quality of life score and all of its components between the intervention's immediate aftermath and one month later was noted (P < 0.05).

CONCLUSION

Home-based palliative care has a positive effect on the quality of life for elderly people who have heart failure, making it a worthwhile intervention to enhance their quality of life.

TRIAL REGISTRATIONS

(IRCT20211213053389N1). Date of registration: (19/02/2022).

Factors associated with hospitalisations of patients with chronic heart failure approaching the end of life: A systematic review

BACKGROUND

Heart failure has high mortality and is linked to substantial burden for patients, carers and health care systems. Patients with chronic heart failure frequently experience recurrent hospitalisations peaking at the end of life, but most prefer to avoid hospital. The drivers of hospitalisations are not well understood.

AIM

We aimed to synthesise the evidence on factors associated with all-cause and heart failure hospitalisations of patients with advanced chronic heart failure.

DESIGN

Systematic review of studies quantitatively evaluating factors associated with all-cause or heart failure hospitalisations in adult patients with advanced chronic heart failure.

DATA SOURCES

Five electronic databases were searched from inception to September 2020. Additionally, searches for grey literature, citation searching and hand-searching were performed. We assessed the quality of individual studies using the QualSyst tool. Strength of evidence was determined weighing number, quality and consistency of studies. Findings are reported narratively as pooling was not deemed feasible.

RESULTS

In 54 articles, 68 individual, illness-level, service-level and environmental factors were identified. We found high/moderate strength evidence for specialist palliative or hospice care being associated with reduced risk of all-cause and heart failure hospitalisations, respectively. Based on high strength evidence, we further identified black/non-white ethnicity as a risk factor for all-cause hospitalisations.

CONCLUSION

Efforts to integrate hospice and specialist palliative services into care may reduce avoidable hospitalisations in advanced heart failure. Inequalities in end-of-life care in terms of race/ethnicity should be addressed. Further research should investigate the causality of the relationships identified here.

Examining Adherence and Dose Effect of an Early Palliative Care Intervention for Advanced Heart Failure Patients

CONTEXT

Research priority guidelines highlight the need for examining the "dose" components of palliative care (PC) interventions, such as intervention adherence and completion rates, that contribute to optimal outcomes.

OBJECTIVES

Examine the "dose" effect of PC intervention completion vs. noncompletion on quality of life (QoL) and healthcare use in patients with advanced heart failure (HF) over 32 weeks.

METHODS

Secondary analysis of the ENABLE CHF-PC intervention trial for patients with New York Heart Association (NYHA) Class III/IV HF. "Completers" defined as completing a single, in-person outpatient palliative care consultation (OPCC) plus 6 weekly, PC nurse coach-led telehealth sessions. "Non-completers" were defined as either not attending the OPCC or completing <6 telehealth sessions. Outcome variables were QoL and healthcare resource use (hospital days; emergency department visits). Mixed models were used to model dose effects for "completers" vs "noncompleters" over 32 weeks.

RESULTS

Of 208 intervention group participants, 81 (38.9%) were classified as "completers" with a mean age of 64.6 years; 72.8% were urban-dwelling; 92.5% had NYHA Class III HF. 'Completers' vs. "non-completers"" groups were well-balanced at baseline; however "noncompleters" did report higher anxiety (6.0 vs 7.0, P < 0.05, d = 0.28). Moderate, clinically significant, improved QoL differences were found at 16 weeks in "completers" vs. "non-completers" (between-group difference: -9.71 (3.18), d = 0.47, P = 0.002) but not healthcare use.

CONCLUSION

Higher intervention completion rates of an early PC intervention was associated with QoL improvements in patients with advanced HF. Future work should focus on identifying the most efficacious "dose" of intervention components and increasing adherence to them.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

Impact of a Palliative Care Education Module in Patients With Heart Failure

Background:

Heart failure (HF) impacts 6.2 million American adults. With no cure, therapies aim to prevent progression and manage symptoms. Inclusion of palliative care (PC) helps improve symptoms and quality of life. Heart failure guidelines recommend the inclusion of PC in HF therapy, but referrals are often delayed.

Objective:

Introduce PC to patients with HF and examine the impact on PC consults, readmission, mortality, and intensive care unit (ICU) transfers.

Methods:

Patients (n = 60) admitted with HF to an academic hospital were asked to view a PC educational module. A number of PC consults, re-admissions, mortality, and transfers to the ICU were compared among participants and those who declined.

Results:

Nine patients in the intervention group (n = 30) requested a PC consult ( P = .042) versus 2 in the usual care group (n = 30; P = .302). There was no statistically significant difference in readmissions, mortality, or ICU transfers between groups.

Conclusions:

Palliative care education increases the likelihood of PC utilization but in this short-term project was not found to statistically impact mortality, re-admissions, or transfers to higher levels of care.

Duration of palliative care before death in international routine practice: a systematic review and meta-analysis

BACKGROUND

Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature.

METHODS

We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death).

RESULTS

One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries.

CONCLUSIONS

Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.

Patients' experiences of attending an adapted cardiac rehabilitation programme for heart failure in a day hospice

BACKGROUND

Heart failure is highly prevalent with poor outcomes, yet only a small proportion of patients receive specialist palliative care services.

AIM

To explore if a programme focusing on support and symptom management of people with heart failure in a hospice environment would be acceptable and of benefit to patients.

METHODS

A pre/post intervention study design using mixed methods was used to evaluate the programme. The programme was delivered in 2-hour time slots over a period of 8 weeks. Participants completed three questionnaires pre- and post- and were interviewed within 1 week of completion. The study was conducted between June 2014 and January 2015.

FINDINGS

A response rate of 51.7% (n=15) was narrowed to a final sample size of 12 patients. The questionnaire results showed a positive impact on participants' wellbeing and views regarding the use of a hospice, but a desire for greater focus on emotional support. Four key themes emerged from inductive qualitative analysis: demystifying perceptions about hospice care; positivity about wellbeing; learning together; and consideration of end-of-life preparation.

CONCLUSION

This adapted programme provides a useful model for the increased integration of palliative care into provision for those living with advancing heart failure.

A Systematic Review of Methods Used for Confounding Adjustment in Observational Economic Evaluations in Cardiology Conducted between 2013 and 2017

Background. Observational economic evaluations (i.e., economic evaluations in which treatment allocation is not randomized) are prone to confounding bias. Prior reviews published in 2013 have shown that adjusting for confounding is poorly done, if done at all. Although these reviews raised awareness on the issues, it is unclear if their results improved the methodological quality of future work. We therefore aimed to investigate whether and how confounding was accounted for in recently published observational economic evaluations in the field of cardiology. Methods. We performed a systematic review of PubMed, Embase, Cochrane Library, Web of Science, and PsycInfo databases using a set of Medical Subject Headings and keywords covering topics in "observational economic evaluations in health within humans" and "cardiovascular diseases." Any study published in either English or French between January 1, 2013, and December 31, 2017, addressing our search criteria was eligible for inclusion in our review. Our protocol was registered with PROSPERO (CRD42018112391). Results. Forty-two (0.6%) out of 7523 unique citations met our inclusion criteria. Fewer than half of the selected studies adjusted for confounding (n = 19 [45.2%]). Of those that adjusted for confounding, propensity score matching (n = 8 [42.1%]) and other matching-based approaches were favored (n = 8 [42.1%]). Our results also highlighted that most authors who adjusted for confounding rarely justified their methodological choices. Conclusion. Our results indicate that adjustment for confounding is often ignored when conducting an observational economic evaluation. Continued knowledge translation efforts aimed at improving researchers' knowledge regarding confounding bias and methods aimed at addressing this issue are required and should be supported by journal editors.

Palliative Care Consultation Reduces Heart Failure Transitions: A Matched Analysis

Background

Palliative care supports quality of life, symptom control, and goal setting in heart failure (HF) patients. Unlike hospice, palliative care does not restrict life‐prolonging therapy. This study examined the association between palliative care during hospitalization for HF on the subsequent transitions and procedures.

Methods and Results

Veterans admitted to hospitals with HF from 2010 to 2015 were randomly selected for the Veterans Administration External Peer Review Program. Variables pertaining to demographic, clinical, laboratory, and usage were captured from Veterans Administration electronic records. Patients receiving hospice services before admission were excluded. Patients who received palliative care were propensity matched to those who did not. The primary outcomes were whether the patient experienced transitions or procedures in the 6 months after admission. Transitions included multiple readmissions (≥2) or intensive care admissions and procedures included mechanical ventilation, pacemaker implantation, or defibrillator implantation. Among 57 182 hospitalized HF patients, 1431 received palliative care, and were well matched to 1431 without (standardized mean differences ≤ ±0.05 on all matched variables). Palliative care was associated with significantly fewer multiple rehospitalizations (30.9% versus 40.3%, P<0.001), mechanical ventilation (2.8% versus 5.4%, P=0.004), and defibrillator implantation (2.1% versus 3.6%, P=0.01). After adjustment for facility fixed effects, palliative care consultation was associated with a significantly reduced hazard of multiple readmissions (adjusted hazard ratio=0.73, 95% CI, 0.64–0.84) and mechanical ventilation (adjusted hazard ratio=0.76, 95% CI, 0.67–0.87).

Conclusions

Palliative care during HF admissions was associated with fewer readmissions and less mechanical ventilation. When available, engagement of HF patients and caregivers in palliative care for symptom control, quality of life, and goals of care discussions may be associated with reduced rehospitalizations and mechanical ventilation.

Association Between Palliative Care and Death at Home in Adults With Heart Failure

Background Palliative care is associated with improved symptom control and quality of life in people with heart failure. There is conflicting evidence as to whether it is associated with a greater likelihood of death at home in this population. The objective of this study was to describe the delivery of newly initiated palliative care services in adults who die with heart failure and measure the association between receipt of palliative care and death at home compared with those who did not receive palliative care. Methods and Results We performed a population-based cohort study using linked health administrative data in Ontario, Canada of 74 986 community-dwelling adults with heart failure who died between 2010 and 2015. Seventy-five percent of community-dwelling adults with heart failure died in a hospital. Patients who received any palliative care were twice as likely to die at home compared with those who did not receive it (adjusted odds ratio 2.12 [95% CI, 2.03-2.20]; P<0.01). Delivery of home-based palliative care had a higher association with death at home (adjusted odds ratio 11.88 [95% CI, 9.34-15.11]; P<0.01), as did delivery during transitions of care between inpatient and outpatient care settings (adjusted odds ratio 8.12 [95% CI, 6.41-10.27]; P<0.01). Palliative care was most commonly initiated late in the course of a person's disease (≤30 days before death, 45.2% of subjects) and led by nonspecialist palliative care physicians 61% of the time. Conclusions Most adults with heart failure die in a hospital. Providing palliative care near the end-of-life was associated with an increased likelihood of dying at home. These findings suggest that scaling existing palliative care programs to increase access may improve end-of-life care in people dying with chronic noncancer illness.

Economic evaluations of palliative care models: A systematic review

BACKGROUND

Palliative care aims to improve quality of life by relieving physical, emotional, and spiritual suffering. Health system planning can be informed by evaluating cost and effectiveness of health care delivery, including palliative care.

AIM

The objectives of this article were to describe and critically appraise economic evaluations of palliative care models and to identify cost-effective models in improving patient-centered outcomes.

DESIGN

We conducted a systematic review and registered our protocol in PROSPERO (CRD42016053973).

DATA SOURCES

A systematic search of nine medical and economic databases was conducted and extended with reference scanning and gray literature. Methodological quality was assessed using the Drummond checklist.

RESULTS

We identified 12,632 articles and 5 were included. We included two modeling studies from the United States and England, and three economic evaluations from England, Australia, and Italy. Two studies compared home-based palliative care models to usual care, and one compared home-based palliative care to no care. Effectiveness outcomes included hospital readmission prevented, days at home, and palliative care symptom severity. All studies concluded that palliative care was cost-effective compared to usual care. The methodological quality was good overall, but three out of five studies were based on small sample sizes.

CONCLUSION

Applicability and generalizability of evidence is uncertain due to small sample sizes, short duration, and limited modeling of costs and effects. Further economic evaluations with larger sample sizes are needed, inclusive of the diversity and complexity of palliative care populations and using patient-centered outcomes.

Multi-disciplinary palliative care is effective in people with symptomatic heart failure: A systematic review and narrative synthesis

BACKGROUND

Despite recommendations, people with heart failure have poor access to palliative care.

AIM

To identify the evidence in relation to palliative care for people with symptomatic heart failure.

DESIGN

Systematic review and narrative synthesis. (PROSPERO CRD42016029911).

DATA SOURCES

Databases (Medline, Cochrane database, CINAHL, PsycINFO, HMIC, CareSearch Grey Literature), reference lists and citations were searched and experts contacted. Two independent reviewers screened titles and abstracts and retrieved papers against inclusion criteria. Data were extracted from included papers and studies were critically assessed using a risk of bias tool according to design.

RESULTS

Thirteen interventional and 10 observational studies were included. Studies were heterogeneous in terms of population, intervention, comparator, outcomes and design rendering combination inappropriate. The evaluation phase studies, with lower risk of bias, using a multi-disciplinary specialist palliative care intervention showed statistically significant benefit for patient-reported outcomes (symptom burden, depression, functional status, quality of life), resource use and costs of care. Benefit was not seen in studies with a single component/discipline intervention or with higher risk of bias. Possible contamination in some studies may have caused under-estimation of effect and missing data may have introduced bias. There was no apparent effect on survival.

CONCLUSION

Overall, the results support the use of multi-disciplinary palliative care in people with advanced heart failure but trials do not identify who would benefit most from specialist palliative referral. There are no sufficiently robust multi-centre evaluation phase trials to provide generalisable findings. Use of common population, intervention and outcomes in future research would allow meta-analysis.

Trends and Predictors of Palliative Care Referrals in Patients With Acute Heart Failure

OBJECTIVE:

To determine the rate and predictors of palliative care referral (PCR) in hospitalized patients with acute heart failure (AHF).

INTRODUCTION:

The PCR is commonly utilized in terminal conditions such as metastatic cancers. There is no data on trends and predictors from large-scale registry of general population regarding PCR in patients with AHF.

METHODS:

For this retrospective study, data were obtained from National Inpatient Sample Database from 2010 to 2014. We used International Classification of Diseases, Ninth Revision diagnosis codes to identify cases with a principle diagnosis of AHF. These patients were divided into 2 groups: (1) PCR, (2) no PCR groups. We performed multivariate analysis to identify predictors of PCRs, as well as reported PCR trends from 2010 to 2014.

RESULTS:

From the database, out of 37 312 324 hospitalizations, 621 947 unweighted cases with primary diagnosis of AHF were selected for further analysis. About 2.8% received PCR. From 2010 to 2014, there was an uptrend from 2.0% to 3.6% for PCR. Metastatic cancer, ventilator-dependent respiratory failure, and cardiogenic shock were strongly associated with PCR. Those who underwent percutaneous coronary intervention and African American or other races were negative predictors for PCR. In the PCR group, 31.4% of patients died during hospitalization.

CONCLUSION:

Palliative care referrals were made in a very small proportion of patients with AHF. We observed steady rise in the PCR utilization. Chronic conditions, advancing age, and high-risk patients were major predictors of PCR.

The feasibility of a randomised controlled trial to compare the cost-effectiveness of palliative cardiology or usual care in people with advanced heart failure: Two exploratory prospective cohorts

Background:

The effectiveness of cardiology-led palliative care is unknown; we have insufficient information to conduct a full trial.

Aim:

To assess the feasibility (recruitment/retention, data quality, variability/sample size estimation, safety) of a clinical trial of palliative cardiology effectiveness.

Design:

Non-randomised feasibility.

Setting/participants:

Unmatched symptomatic heart failure patients on optimal cardiac treatment from (1) cardiology-led palliative service (caring together group) and (2) heart failure liaison service (usual care group).

Outcomes/safety:

Symptoms (Edmonton Symptom Assessment Scale), Kansas City Cardiomyopathy Questionnaire, performance, understanding of disease, anticipatory care planning, cost-effectiveness, survival and carer burden.

Results:

A total of 77 participants (caring together group = 43; usual care group = 34) were enrolled (53% men; mean age 77 years (33–100)). The caring together group scored worse in Edmonton Symptom Assessment Scale (43.5 vs 35.2) and Kansas City Cardiomyopathy Questionnaire (35.4 vs 39.9). The caring together group had a lower consent/screen ratio (1:1.7 vs 1: 2.8) and few died before approach (0.08% vs 16%) or declined invitation (17% vs 37%).

Data quality:

At 4 months, 74% in the caring together group and 71% in the usual care group provided data. Most attrition was due to death or deterioration. Data quality in self-report measures was otherwise good.

Safety:

There was no difference in survival. Symptoms and quality of life improved in both groups. A future trial requires 141 (202 allowing 30% attrition) to detect a minimal clinical difference (1 point) in Edmonton Symptom Assessment Scale score for breathlessness (80% power). More participants (176; 252 allowing 30% attrition) are needed to detect a 10.5 change in Kansas City Cardiomyopathy Questionnaire score (80% power; minimum clinical difference = 5).

Conclusion:

A trial to test the clinical effectiveness (improvement in breathlessness) of cardiology-led palliative care is feasible.

Multicomponent Palliative Care Interventions in Advanced Chronic Diseases: A Systematic Review

BACKGROUND

Many patients live with serious chronic or terminal illnesses. Multicomponent palliative care interventions have been increasingly utilized in patient care; however, it is unclear what is being implemented and who is delivering these interventions.

OBJECTIVES

To (1) describe the delivery of multicomponent palliative care interventions, (2) characterize the disciplines delivering care, (3) identify the components being implemented, and (4) analyze whether the number of disciplines or components being implemented are associated with positive outcomes.

DESIGN

Systematic review.

STUDY SELECTION

English-language articles analyzing multicomponent palliative care interventions.

OUTCOMES MEASURED

Delivery of palliative interventions by discipline, components of palliative care implemented, and number of positive outcomes (eg, pain, quality of life).

RESULTS

Our search strategy yielded 71 articles, which detailed 64 unique multicomponent palliative care interventions. Nurses (n = 64, 88%) were most often involved in delivering care, followed by physicians (n = 43, 67%), social workers (n = 33, 52%), and chaplains (n = 19, 30%). The most common palliative care components patients received were symptom management (n = 56, 88%), psychological support/counseling (n = 52, 81%), and disease education (n = 48, 75%). Statistical analysis did not uncover an association between number of disciplines or components and positive outcomes.

CONCLUSIONS

While there has been growth in multicomponent palliative care interventions over the past 3 decades, important aspects require additional study such as better inclusion of key groups (eg, chronic obstructive pulmonary disease, end-stage renal disease, minorities, older adults); incorporating core components of palliative care (eg, interdisciplinary team, integrating caregivers, providing spiritual support); and developing ways to evaluate the effectiveness of interventions that can be readily replicated and disseminated.

A Quality Improvement Project to Identify Patients With Advanced Heart Failure for Potential Palliative Care Referral in Telemetry and Cardiac Intensive Care Units

Background: Although national guidelines recommend timely initiation of palliative care for hospitalized patients with advanced heart failure (AHF), providers may not recognize which patients who have heart failure are most in need of consultation. Measures: A tool was developed and pilot-tested to screen patients admitted to a cardiology inpatient service with a left ventricular ejection fraction (LVEF) of 50% or less for potential triggers signifying palliative care needs in the telemetry or cardiac intensive care unit (CICU). Intervention: The tool was completed during cardiology rounds. Outcomes: Of the 21 patients evaluated, the median LVEF was lower in the telemetry group (22%) than in the CICU group (28%). Trigger patients in the telemetry unit were less adherent to medical management (χ² = 6.034, p = .014) and had greater psychosocial and spiritual needs (χ² = 3.956, p = .047) than those in the CICU. Conclusion: We describe a feasible palliative care screening tool for patients with AHF hospitalized in a telemetry unit or CICU that may identify opportunities for early palliative care referrals. Additional study is needed to determine whether this tool can be used to improve patient care or patient outcomes.

Multidisciplinary Approach for Patients Hospitalized With Heart Failure

Acute heart failure describes the rapid deterioration, over minutes, days or hours, of symptoms and signs of heart failure. Its management is an interdisciplinary challenge that requires the cooperation of various specialists. While emergency providers, (interventional) cardiologists, heart surgeons, and intensive care specialists collaborate in the initial stabilization of acute heart failure patients, the involvement of nurses, discharge managers, and general practitioners in the heart failure team may facilitate the transition from inpatient care to the outpatient setting and improve acute heart failure readmission rates. This review highlights the importance of a multidisciplinary approach to acute heart failure with particular focus on the chain-of-care delivered by the various services within the healthcare system.

Palliative Care Interventions for Patients with Heart Failure: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically characterize interventions and effectiveness of palliative care for advanced heart failure (HF) patients.

BACKGROUND

Patients with advanced heart failure experience a high burden of distressing symptoms and diminished quality of life. Palliative care expertise with symptom management and healthcare decision-making benefits HF patients.

METHODS

A systematic PubMed search was conducted from inception to June 2016 for studies of palliative care interventions for HF patients. Studies of humans with a HF diagnosis who underwent a palliative care intervention were included. Data were extracted on study design, participant characteristics, intervention components, and in three groups of outcomes: patient-centered outcomes, quality-of-death outcomes, and resource utilization. Study characteristics were examined to determine if meta-analysis was possible.

RESULTS

The fifteen identified studies varied in design (prospective, n = 10; retrospective, n = 5). Studies enrolled older patients, but greater variability was found for race, sex, and marital status. A majority of studies measuring patient-centered outcomes demonstrated improvements including quality of life and satisfaction. Quality-of-death outcomes were mixed with a majority of studies reporting clarification of care preferences, but less improvement in death at home and hospice enrollment. A meta-analysis in three studies found that home-based palliative care consults in HF patients lower the risk of rehospitalization by 42% (RR = 0.58; 95% Confidence Interval 0.44, 0.77).

DISCUSSION

Available evidence suggests that home and team-based palliative interventions for HF patients improve patient-centered outcomes, documentation of preferences, and utilization. Increased high quality studies will aid the determination of the most effective palliative care approaches for the HF population.

Integrated palliative care in Europe: a qualitative systematic literature review of empirically-tested models in cancer and chronic disease

BACKGROUND

Integrated Palliative Care (PC) strategies are often implemented following models, namely standardized designs that provide frameworks for the organization of care for people with a progressive life-threatening illness and/or for their (in)formal caregivers. The aim of this qualitative systematic review is to identify empirically-evaluated models of PC in cancer and chronic disease in Europe. Further, develop a generic framework that will consist of the basis for the design of future models for integrated PC in Europe.

METHODS

Cochrane, PubMed, EMBASE, CINAHL, AMED, BNI, Web of Science, NHS Evidence. Five journals and references from included studies were hand-searched. Two reviewers screened the search results. Studies with adult patients with advanced cancer/chronic disease from 1995 to 2013 in Europe, in English, French, German, Dutch, Hungarian or Spanish were included. A narrative synthesis was used.

RESULTS

14 studies were included, 7 models for chronic disease, 4 for integrated care in oncology, 2 for both cancer and chronic disease and 2 for end-of-life pathways. The results show a strong agreement on the benefits of the involvement of a PC multidisciplinary team: better symptom control, less caregiver burden, improvement in continuity and coordination of care, fewer admissions, cost effectiveness and patients dying in their preferred place.

CONCLUSION

Based on our findings, a generic framework for integrated PC in cancer and chronic disease is proposed. This framework fosters integration of PC in the disease trajectory concurrently with treatment and identifies the importance of employing a PC-trained multidisciplinary team with a threefold focus: treatment, consulting and training.