End-of-life and palliative care provision to adults with congenital heart disease: mortality follow-back study using administrative data

Background

Although many adults with congenital heart disease (CHD) still die prematurely, end-of-life care for these patients receives limited attention. There are indications that current care provision at the end of life is burdensome, expensive, and not in line with patients' needs and preferences. We sought to analyse end-of-life care in adult CHD patients to determine whether health services need to be optimized.

Purpose

This study aimed to describe patterns of healthcare consumption of adults with CHD who died in the last year of life.

Methods

This retrospective mortality follow-back study used data of the BELgian COngenital heart disease Database combining Administrative and Clinical data (BELCODAC), including individually linked healthcare claims, death certificates and clinical data from adults with CHD in Flanders (Belgium). For this study, adults with CHD who died between 2007 and 2016 from any cause except sudden death, accident or violence, were selected for inclusion. Accidental, violent, and sudden deaths were identified based on causes of death and healthcare use in the last 3 months of life. Healthcare consumption was based on nomenclature codes derived from healthcare claims data.

Results

A total of 327 eligible patients (median age: 58 y; 54% women; 43% mild CHD; 45% moderate CHD; 11% complex CHD; 49% cardiovascular cause of death) were identified. During the last year of life, healthcare use increased substantially (Fig. 1). During the last month of life, 54% of patients were hospitalised, 55% visited the emergency department, and 15% were admitted to an intensive care unit at least once (Fig. 2). A total of 8% and 5% of patients underwent heart surgery or catherization in the last month of life, respectively. Furthermore, 70% of patients had at least one encounter with a general practitioner and 11% with a CHD specialist in the last month of life. Specialist palliative care was provided to 13% of patients in the last month of life.

When looking at the subgroup of patients with CHD that died due to a cardiovascular cause, proportions of patients that were hospitalised or had visits at the emergency department or intensive care unit in the last month of life were similar (Fig. 2). However, these patients underwent more heart surgeries (11%) and catherizations (8%), had more encounters with CHD specialists (15%), and received remarkably less specialized palliative care (4%) in the last month of life.

Conclusion

Resource utilization increased substantially during the last year of life, resulting in high acute healthcare consumption in the last month of life. It is remarkable that only a minority of patients received palliative care, especially when looking at patients who died due to a cardiovascular cause. Our findings motivate the need to assess if and how end-of-life is planned for adults with CHD. Future studies using qualitative analyses and survey methodology are needed to optimize the management of end-of-life care.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Research Foundation Flanders, European Society of Cardiology, Koning Boudewijnstichting, National Foundation on Research in Pediatric Cardiology, Swedish Research Council for Health, Working Life and Welfare-FORTE

Healthcare use at the end of life of patients with congenital heart disease: does heart failure matter?

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Research Foundation Flanders (to PM, EG, and LVB)

European Society of Cardiology (Nursing Training Grant to LVB)

Background

Heart failure (HF) is a common cause of morbidity and mortality in patients with congenital heart disease (CHD). Although limited in scope, previous studies suggest that patients with heart failure follow a specific end-of-life trajectory with episodes of serious complications, which may impact the patterns of care as death approaches.

Aims

The study aims to identify differences in characteristics and patterns of care in the last year of life in deceased CHD patients with and without HF.

Methods

This retrospective study used data of deceased adult patients included in the BELgian COngenital heart disease Database combining Administrative and Clinical data (BELCODAC). To describe patterns of care in the last year of life, we captured information about hospitalisations, emergency department visits, and visits to the general practitioner using nomenclature codes. Heart failure was identified as having HF as cause of death and/or at least one prescription of a loop diuretic in the last year of life. Sensitivity analyses with a stricter definition for HF (HF as cause of death or ≥ 1 prescription of a loop diuretic combined with a prescription of digoxin, dopamine, dobutamine, other non-glycoside stimulants, metoprolol, bisoprolol, carvedilol, aldosterone antagonists, ACE inhibitors or ARBs) were performed as well.

Results

During the period 2007–2016, 390 adults with CHD died, of which 170 patients with HF (44%). Patients with HF were older, died more often due to a cardiovascular cause of death, and had more complex heart lesions, compared to patients without HF (Table 1). While the number of emergency department visits and hospitalisations in the last year was similar, patients with HF had almost twice as much monthly visits at the general practitioner in their last year of life (Table 1). As shown in Figure 1, the mean number of hospitalisations and emergency department visits increased in a similar fashion throughout the last year of life, but the pattern of general practitioner visits was substantially different for patients with and without HF. The sensitivity analyses, in which a stricter definition for HF was used, yield very similar results. In these analyses, the difference in mean monthly hospitalisations was also significant between the two groups.

Conclusions

This study shows clinically important differences in characteristics and patterns of care of deceased patients with CHD with and without heart failure. Patients with HFhave different needs and should receive a tailored approach at the end of life. Future research is needed to understand these differences and investigate these patients' end-of-life care needs in more detail.

Funding acknowledgments: This work was supported by Research Foundation Flanders; European Society of Cardiology; the King Baudouin Foundation; the National Foundation on Research in Pediatric Cardiology; and the Swedish Research Council for Health, Working Life and Welfare-FORTE.

Provision of palliative care to adults with congenital heart disease at the end of life

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by Research Foundation Flanders [grant numbers G097516N to PM, 12E9816N to EG and 1154719N to LVB]; the King Baudouin Foundation (Fund Joseph Oscar Waldmann-Berteau & Fund Walckiers Van Dessel); the National Foundation on Research in Pediatric Cardiology; and the Swedish Research Council for Health, Working Life and Welfare -FORTE (grant number STYA-2018/0004).

OnBehalf

BELCODAC consortium

Background

Although recent position papers have discussed and advocated for the integration of palliative care in the treatment course of adults with congenital heart defects (CHD), empirical studies reporting to what extent palliative care is currently provided, are still lacking.

Purpose

(1) To explore the current provision of palliative care to adults with CHD in the last 6 months of their life; and (2) to describe the profile of patients who received palliative care.

Methods

In this retrospective study, data of deceased adult patients included in the BELgian COngenital heart disease Database combining Administrative and Clinical data (BELCODAC) were analysed. Palliative care provision (i.e., admission to palliative care ward, or palliative care at home) was identified using nomenclature codes. The level of anatomical complexity was based on the Bethesda classification. Descriptive analyses were performed.

Results

During the period 2006-2016, 480 adults with CHD died (mean age: 54.4y; 45% simple CHD, 43% moderate CHD, 12% complex CHD). We identified that 75 patients (16%) had at least one nomenclature code linked to palliative care in the last 6 months of their life. More specifically, 16 patients were admitted to an inpatient palliative care service and 67 patients received palliative care at home. Of the patients who received palliative care at home, 40 patients were cared for by a multidisciplinary team specialized in palliative care provision and 59 patients received care from nurses and/or general practitioners while being recognized as a palliative patient. A total of 8 patients received palliative care both at the inpatient palliative care service and at home.

Of the 75 patients receiving palliative care, 44 (59%) had a neoplasm as the primary cause of death and a cardiac cause of death was reported for 10 patients (13%) (see Figure 1). The mean age of patients receiving palliative care was 57.9 years. Most patients receiving palliative care had a simple CHD (n = 40; 53%), 29 patients (39%) had a moderate lesion, and 6 patients (8%) had a complex lesion. That means that, respectively, 19%, 14%, and 11% of all deceased patients with a simple, moderate, and complex heart lesion received palliative care.

Conclusions

This is the first exploratory study on palliative care in adults with CHD. About one in six patients who died received palliative care. Of those who received palliative care, the cause of death was in most cases of a non-cardiac nature. Further research is needed to investigate the care trajectories and care needs of adults with CHD in the last months of life.

Figure 1. Causes of death of adults with CHD who received palliative care in the last 6 months of life (n = 75).

A 10-day vacancy period after cleaning and disinfection has no effect on the bacterial load in pig nursery units

BACKGROUND

Biosecurity measures such as cleaning, disinfection and a vacancy period between production cycles on pig farms are essential to prevent disease outbreaks. No studies have tested the effect of a longer vacancy period on bacterial load in nursery units.

METHODS

The present study evaluated the effect of a 10-day vacancy period in pig nursery units on total aerobic flora, Enterococcus spp., Escherichia coli, faecal coliforms and methicillin resistant Staphylococcus aureus (MRSA). Three vacancy periods of 10 days were monitored, each time applied in 3 units. The microbiological load was measured before disinfection and at 1, 4, 7 and 10 days after disinfection.

RESULTS

No significant decrease or increase in E. coli, faecal coliforms, MRSA and Enterococcus spp. was noticed. Total aerobic flora counts were the lowest on day 4 after disinfection (i.e. 4.07 log CFU/625 cm2) (P < 0.05), but the difference with other sampling moments was limited (i.e. 0.6 log CFU/625 cm2) and therefore negligible. Furthermore, this observation on day 4 was not confirmed for the other microbiological parameters. After disinfection, drinking nipples were still mostly contaminated with total aerobic flora (i.e. 5.32 log CFU/625 cm2) and Enterococcus spp. (i.e. 95 % of the samples were positive) (P < 0.01); the feeding troughs were the cleanest location (total aerobic flora: 3.53 log CFU/625 cm2 and Enterococcus spp.: 50 % positive samples) (P < 0.01).

CONCLUSIONS

This study indicates that prolonging the vacancy period in nursery units to 10 days after disinfection with no extra biosecurity measures has no impact on the environmental load of total aerobic flora, E. coli, faecal coliforms, MRSA and Enterococcus spp..

Comparison of competitive exclusion with classical cleaning and disinfection on bacterial load in pig nursery units

Background

Colonisation of the environment of nursery units by pathogenic micro-organisms is an important factor in the persistence and spread of endemic diseases in pigs and zoonotic pathogens. These pathogens are generally controlled by the use of antibiotics and disinfectants. Since an increasing resistance against these measures has been reported in recent years, methods such as competitive exclusion (CE) are promoted as promising alternatives.

Results

This study showed that the infection pressure in CE units after microbial cleaning was not reduced to the same degree as in control units. Despite sufficient administration of probiotic-type spores, the analysed bacteria did not decrease in number after 3 production rounds in CE units, indicating no competitive exclusion. In addition, no differences in feed conversion were found between piglets raised in CE and control units in our study. Also, no differences in faecal consistency (indicator for enteric diseases) was noticed.

Conclusion

These results indicate that the CE protocol is not a valuable alternative for classical C&D.

Comparison of sampling procedures and microbiological and non-microbiological parameters to evaluate cleaning and disinfection in broiler houses

Cleaning and disinfection of the broiler stable environment is an essential part of farm hygiene management. Adequate cleaning and disinfection is essential for prevention and control of animal diseases and zoonoses. The goal of this study was to shed light on the dynamics of microbiological and non-microbiological parameters during the successive steps of cleaning and disinfection and to select the most suitable sampling methods and parameters to evaluate cleaning and disinfection in broiler houses. The effectiveness of cleaning and disinfection protocols was measured in six broiler houses on two farms through visual inspection, adenosine triphosphate hygiene monitoring and microbiological analyses. Samples were taken at three time points: 1) before cleaning, 2) after cleaning, and 3) after disinfection. Before cleaning and after disinfection, air samples were taken in addition to agar contact plates and swab samples taken from various sampling points for enumeration of total aerobic flora, Enterococcus spp., and Escherichia coli and the detection of E. coli and Salmonella. After cleaning, air samples, swab samples, and adenosine triphosphate swabs were taken and a visual score was also assigned for each sampling point. The mean total aerobic flora determined by swab samples decreased from 7.7±1.4 to 5.7±1.2 log CFU/625 cm2 after cleaning and to 4.2±1.6 log CFU/625 cm2 after disinfection. Agar contact plates were used as the standard for evaluating cleaning and disinfection, but in this study they were found to be less suitable than swabs for enumeration. In addition to measuring total aerobic flora, Enterococcus spp. seemed to be a better hygiene indicator to evaluate cleaning and disinfection protocols than E. coli. All stables were Salmonella negative, but the detection of its indicator organism E. coli provided additional information for evaluating cleaning and disinfection protocols. Adenosine triphosphate analyses gave additional information about the hygiene level of the different sampling points.

Sentinels in a climatic outpost: Endoparasites in the introduced muskox (Ovibos moschatus wardi) population of Dovrefjell, Norway

We assessed the occurrence of endoparasite eggs, cysts, oocysts and larvae in the muskox population of Dovrefjell, Norway, during June and August 2012. This population originates from 13 calves translocated from Eastern Greenland during the 1950s. A total of 167 faecal samples were collected, of which 49% came from identified individuals: 165 were examined by the Baermann and 95 by McMaster techniques and 167 by immunofluorescence antibody test (IFAT). Lungworm larvae recovered in the Baermanns were identified as Protostrongylidae (82%) and Dictyocaulus sp. (76%) based on morphology. Further molecular analyses of the ITS-2 region of two protostrongylid larvae from two muskoxen as Muellerius capillaris. Larval prevalence and intensity differed significantly between samples collected from the different age groups in June and August, with increasing prevalence and intensity in calves during the course of their first summer, whereas intensity decreased in adults from June to August. McMaster test and IFAT were used to determine the occurrence of infections with intestinal strongyles (84%), Moniezia spp. (24%), Nematodirus sp. (2%), Eimeria spp. (98%), Cryptosporidium sp. (14%) and Giardia duodenalis (7%). Molecular analyses of three isolates of Cryptosporidium and Giardia were identified as Cryptosporidium xiaoi and G. duodenalis assemblage A. Although infection intensity of all these intestinal parasites tended to be low, the high level of polyparasitism, together with the other challenges faced by this population living at the edge of their climatic range, means that these infections should not be ignored. The potential that M. capillaris, Cryptosporidium and Giardia infections derive from other sympatric host species (sheep and reindeer) is discussed.

Value of transcranial Doppler examination in the diagnosis of cerebral vasospasm after subarachnoid hemorrhage

In 21 patients with subarachnoid hemorrhage secondary to ruptured intracranial aneurysms, we performed serial neurological evaluations, transcranial Doppler examinations, and cerebral blood flow (CBF) determinations. We classified 8 patients as having vasospasm (delayed neurological deterioration, appropriate reduction of CBF) and 13 patients as having no spasm on the basis of this information. Transcranial Doppler flow velocities in the middle cerebral artery and the anterior cerebral artery were significantly elevated for the group with vasospasm on posthemorrhage Days 4 through 12. Elevation of transcranial Doppler velocities preceded clinical signs of cerebral ischemia. The maximal transcranial Doppler flow velocities achieved were compared on the basis of the extent of clot on early computed tomographic (CT) scans. The mean anterior cerebral artery flow velocities were significantly different between CT Grades II and III. The initial transcranial Doppler flow velocities were compared on the basis of the patient's Hunt and Hess grade upon admission. The flow velocities for Grade V patients were significantly lower than those for Grade IV patients. Transcranial Doppler flow velocities were compared with arteriographically observed anterior cerebral artery and middle cerebral artery radii in 12 instances. The correlation was poor, but the data should be interpreted cautiously in view of the small number of arteriograms. We conclude that transcranial Doppler examination has considerable potential in the early diagnosis of delayed ischemic neurological deficit (clinical vasospasm) in patients with subarachnoid hemorrhage.