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Stockdill ML, Dionne-Odom JN, Wells R, Ejem D, Azuero A, Keebler K, Sockwell E, Tims S, Burgio KL, Engler S, Durant R, Pamboukian SV, Tallaj J, Swetz KM, Kvale E, Tucker R, Bakitas M. African American Recruitment in Early Heart Failure Palliative Care Trials: Outcomes and Comparison With the ENABLE CHF-PC Randomized Trial. J Palliat Care 2023; 38:52-61. [PMID: 33258422 PMCID: PMC8314978 DOI: 10.1177/0825859720975978] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Palliative care trial recruitment of African Americans (AAs) is a formidable research challenge. OBJECTIVES Examine AA clinical trial recruitment and enrollment in a palliative care randomized controlled trial (RCT) for heart failure (HF) patients and compare patient baseline characteristics to other HF palliative care RCTs. METHODS This is a descriptive analysis the ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends: Comprehensive Heartcare for Patients and Caregivers) RCT using bivariate statistics to compare racial and patient characteristics and differences through recruitment stages. We then compared the baseline sample characteristics among three palliative HF trials. RESULTS Of 785 patients screened, 566 eligible patients with NYHA classification III-IV were approached; 461 were enrolled and 415 randomized (AA = 226). African Americans were more likely to consent than Caucasians (55%; P FDR = .001), were younger (62.7 + 8; P FDR = .03), had a lower ejection fraction (39.1 + 15.4; PFDR = .03), were more likely to be single (P FDR = .001), and lack an advanced directive (16.4%; P FDR < .001). AAs reported higher goal setting (3.3 + 1.3; P FDR = .007), care coordination (2.8 + 1.3; P FDR = .001) and used more "denial" coping strategies (0.8 + 1; P FDR = .001). Compared to two recent HF RCTs, the ENABLE CHF-PC sample had a higher proportion of AAs and higher baseline KCCQ clinical summary scores. CONCLUSION ENABLE CHF-PC has the highest reported recruitment rate and proportion of AAs in a palliative clinical trial to date. Community-based recruitment partnerships, recruiter training, ongoing communication with recruiters and clinician co-investigators, and recruiter racial concordance likely contributed to successful recruitment of AAs. These important insights provide guidance for design of future HF palliative RCTs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02505425.
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Affiliation(s)
- Macy L. Stockdill
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Konda Keebler
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth Sockwell
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sheri Tims
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kathryn L. Burgio
- Division of Gerontology, Department of Medicine, Geriatrics, Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sally Engler
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Raegan Durant
- Division of Preventative Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Salpy V. Pamboukian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jose Tallaj
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Keith M. Swetz
- Division of Gerontology, Department of Medicine, Geriatrics, Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth Kvale
- Department of Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Rodney Tucker
- Department of Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Marie Bakitas
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
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Bakitas MA, Dionne-Odom JN, Ejem DB, Wells R, Azuero A, Stockdill ML, Keebler K, Sockwell E, Tims S, Engler S, Steinhauser K, Kvale E, Durant RW, Tucker RO, Burgio KL, Tallaj J, Swetz KM, Pamboukian SV. Effect of an Early Palliative Care Telehealth Intervention vs Usual Care on Patients With Heart Failure: The ENABLE CHF-PC Randomized Clinical Trial. JAMA Intern Med 2020; 180:1203-1213. [PMID: 32730613 PMCID: PMC7385678 DOI: 10.1001/jamainternmed.2020.2861] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE National guidelines recommend early palliative care for patients with advanced heart failure, which disproportionately affects rural and minority populations. OBJECTIVE To determine the effect of an early palliative care telehealth intervention over 16 weeks on the quality of life, mood, global health, pain, and resource use of patients with advanced heart failure. DESIGN, SETTING, AND PARTICIPANTS A single-blind, intervention vs usual care randomized clinical trial was conducted from October 1, 2015, to May 31, 2019, among 415 patients 50 years or older with New York Heart Association class III or IV heart failure or American College of Cardiology stage C or D heart failure at a large Southeastern US academic tertiary medical center and a Veterans Affairs medical center serving high proportions of rural dwellers and African American individuals. INTERVENTIONS The ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers) intervention comprises an in-person palliative care consultation and 6 weekly nurse-coach telephonic sessions (20-40 minutes) and monthly follow-up for 48 weeks. MAIN OUTCOMES AND MEASURES Primary outcomes were quality of life (as measured by the Kansas City Cardiomyopathy Questionnaire [KCCQ]: score range, 0-100; higher scores indicate better perceived health status and clinical summary scores ≥50 are considered "fairly good" quality of life; and the Functional Assessment of Chronic Illness Therapy-Palliative-14 [FACIT-Pal-14]: score range, 0-56; higher scores indicate better quality of life) and mood (as measured by the Hospital Anxiety and Depression Scale [HADS]) over 16 weeks. Secondary outcomes were global health (Patient Reported Outcome Measurement System Global Health), pain (Patient Reported Outcome Measurement System Pain Intensity and Interference), and resource use (hospital days and emergency department visits). RESULTS Of 415 participants (221 men; baseline mean [SD] age, 63.8 [8.5] years) randomized to ENABLE CHF-PC (n = 208) or usual care (n = 207), 226 (54.5%) were African American, 108 (26.0%) lived in a rural area, and 190 (45.8%) had a high-school education or less, and a mean (SD) baseline KCCQ score of 52.6 (21.0). At week 16, the mean (SE) KCCQ score improved 3.9 (1.3) points in the intervention group vs 2.3 (1.2) in the usual care group (difference, 1.6; SE, 1.7; d = 0.07 [95% CI, -0.09 to 0.24]) and the mean (SE) FACIT-Pal-14 score improved 1.4 (0.6) points in the intervention group vs 0.2 (0.5) points in the usual care group (difference, 1.2; SE, 0.8; d = 0.12 [95% CI, -0.03 to 0.28]). There were no relevant between-group differences in mood (HADS-anxiety, d = -0.02 [95% CI, -0.20 to 0.16]; HADS-depression, d = -0.09 [95% CI, -0.24 to 0.06]). CONCLUSIONS AND RELEVANCE This randomized clinical trial with a majority African American sample and baseline good quality of life did not demonstrate improved quality of life or mood with a 16-week early palliative care telehealth intervention. However, pain intensity and interference (secondary outcomes) demonstrated a clinically important improvement. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02505425.
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Affiliation(s)
- Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham.,Division of Gerontology, Geriatrics and Palliative Care, UAB Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, Birmingham.,Division of Gerontology, Geriatrics and Palliative Care, UAB Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Deborah B Ejem
- School of Nursing, University of Alabama at Birmingham, Birmingham.,Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, Birmingham
| | - Macy L Stockdill
- School of Nursing, University of Alabama at Birmingham, Birmingham
| | - Konda Keebler
- School of Nursing, University of Alabama at Birmingham, Birmingham
| | - Elizabeth Sockwell
- School of Nursing, University of Alabama at Birmingham, Birmingham.,Division of Gerontology, Geriatrics and Palliative Care, UAB Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Sheri Tims
- School of Nursing, University of Alabama at Birmingham, Birmingham.,Division of Gerontology, Geriatrics and Palliative Care, UAB Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Sally Engler
- School of Nursing, University of Alabama at Birmingham, Birmingham
| | - Karen Steinhauser
- Center for Innovation, Veterans Affairs Medical Center, Durham, North Carolina.,Department of Population Health Sciences, Division of General Internal Medicine, Duke University, Durham, North Carolina.,Department of Medicine, Division of General Internal Medicine, Duke University, Durham, North Carolina
| | - Elizabeth Kvale
- Department of Medicine, Dell Medical School, University of Texas at Austin, Austin
| | - Raegan W Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Rodney O Tucker
- Division of Gerontology, Geriatrics and Palliative Care, UAB Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Kathryn L Burgio
- Division of Gerontology, Geriatrics and Palliative Care, UAB Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham.,Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Jose Tallaj
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Keith M Swetz
- Division of Gerontology, Geriatrics and Palliative Care, UAB Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham.,Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Salpy V Pamboukian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham
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Dionne-Odom JN, Ejem DB, Wells R, Azuero A, Stockdill ML, Keebler K, Sockwell E, Tims S, Engler S, Kvale E, Durant RW, Tucker RO, Burgio KL, Tallaj J, Pamboukian SV, Swetz KM, Bakitas MA. Effects of a Telehealth Early Palliative Care Intervention for Family Caregivers of Persons With Advanced Heart Failure: The ENABLE CHF-PC Randomized Clinical Trial. JAMA Netw Open 2020; 3:e202583. [PMID: 32282044 PMCID: PMC7154802 DOI: 10.1001/jamanetworkopen.2020.2583] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE Family caregivers of persons with advanced heart failure perform numerous daily tasks to assist their relatives and are at high risk for distress and poor quality of life. OBJECTIVE To determine the effect of a nurse-led palliative care telehealth intervention (Educate, Nurture, Advise, Before Life Ends Comprehensive Heart Failure for Patients and Caregivers [ENABLE CHF-PC]) on quality of life and mood of family caregivers of persons with New York Heart Association Class III/IV heart failure over 16 weeks. DESIGN, SETTING, AND PARTICIPANTS This single-blind randomized clinical trial enrolled caregivers aged 18 years and older who self-identified as an unpaid close friend or family member who knew the patient well and who was involved with their day-to-day medical care. Participants were recruited from outpatient heart failure clinics at a large academic tertiary care medical center and a Veterans Affairs medical center from August 2016 to October 2018. INTERVENTION Four weekly psychosocial and problem-solving support telephonic sessions lasting between 20 and 60 minutes facilitated by a trained nurse coach plus monthly follow-up for 48 weeks. The usual care group received no additional intervention. MAIN OUTCOMES AND MEASURES The primary outcomes were quality of life (measured using the Bakas Caregiver Outcomes Scale), mood (anxiety and/or depressive symptoms measured using the Hospital Anxiety and Depression Scale), and burden (measured using the Montgomery-Borgatta Caregiver Burden scales) over 16 weeks. Secondary outcomes were global health (measured using the PROMIS Global Health instrument) and positive aspects of caregiving. RESULTS A total of 158 family caregivers were randomized, 82 to the intervention and 76 to usual care. The mean (SD) age was 57.9 (11.6) years, 135 (85.4%) were female, 82 (51.9%) were African American, and 103 (65.2%) were the patient's spouse or partner. At week 16, the mean (SE) Bakas Caregiver Outcomes Scale score was 66.9 (2.1) in the intervention group and 63.9 (1.7) in the usual care group; over 16 weeks, the mean (SE) Bakas Caregiver Outcomes Scale score improved 0.7 (1.7) points in the intervention group and 1.1 (1.6) points in the usual care group (difference, -0.4; 95% CI, -5.1 to 4.3; Cohen d = -0.03). At week 16, no relevant between-group differences were observed between the intervention and usual care groups for the Hospital Anxiety and Depression Scale anxiety measure (mean [SE] improvement from baseline, 0.3 [0.3] vs 0.4 [0.3]; difference, -0.1 [0.5]; d = -0.02) or depression measure (mean [SE] improvement from baseline, -0.2 [0.4] vs -0.3 [0.3]; difference, 0.1 [0.5]; d = 0.03). No between-group differences were observed in the Montgomery-Borgatta Caregiver Burden scales (d range, -0.18 to 0.0). Differences in secondary outcomes were also not significant (d range, -0.22 to 0.0). CONCLUSIONS AND RELEVANCE This 2-site randomized clinical trial of a telehealth intervention for family caregivers of patients with advanced heart failure, more than half of whom were African American and most of whom were not distressed at baseline, did not demonstrate clinically better quality of life, mood, or burden compared with usual care over 16 weeks. Future interventions should target distressed caregivers and assess caregiver effects on patient outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02505425.
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Affiliation(s)
- J. Nicholas Dionne-Odom
- University of Alabama at Birmingham School of Nursing
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | | | - Rachel Wells
- University of Alabama at Birmingham School of Nursing
| | - Andres Azuero
- University of Alabama at Birmingham School of Nursing
| | | | - Konda Keebler
- University of Alabama at Birmingham School of Nursing
| | | | - Sheri Tims
- University of Alabama at Birmingham School of Nursing
| | - Sally Engler
- University of Alabama at Birmingham School of Nursing
| | - Elizabeth Kvale
- Department of Medicine, Dell Medical School, The University of Texas at Austin
| | - Raegan W. Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham
| | - Rodney O. Tucker
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | | | - Jose Tallaj
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham
| | - Salpy V. Pamboukian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham
| | - Keith M. Swetz
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - Marie A. Bakitas
- University of Alabama at Birmingham School of Nursing
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
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