The use of hospital-based services by heart failure patients in the last year of life: a discussion paper

Heart failure and the cost of dying: must the ferryman always be paid?

BACKGROUND

Provision of palliative care in chronic heart failure (CHF) can support complex decision-making, significantly improve quality of life and may lower healthcare costs.

AIMS

To examine whether healthcare costs differed in terminal admissions according to the adoption of a palliative approach.

DESIGN

Retrospective review of medical records and costing data for all admissions resulting in death from CHF (July 2011 to December 2019), analysed as two groups (2011-2016 and 2016-2019) because of background changes in costings.

SETTING

Admissions with CHF resulting in death in an Australian tertiary referral centre.

RESULTS

The cohort (n = 439) were elderly (median age 83.7 years, interquartile range (IQR) = 77.6-88.7 years) and mostly men (54.9%). Half (230, 52.4%) were referred to a specialist palliative care team, whereas over a third (172, 39.2%) received a palliative approach. Receiving a palliative approach was associated with a nonstatistically significant lower admission cost (AU$12 710 vs AU$15 978; P = 0.19) between 2011 and 2016 (n = 101, 38.8%) and a significantly lower cost (AU$11 319 vs AU$15 978; P < 0.01) between 2016 and 2019 (n = 71, 39.7%). Intensive care admission resulted in the single greatest additional cost at AU$14 624 (IQR = AU$4130-AU$44 197) (n = 48, 2011-2016). Median terminal admission cost was lower for patients with comfort goals of care (P < 0.01), without life-sustaining interventions (P < 0.01) or who received a palliative approach (P < 0.01). Referral to inpatient specialist palliative care or receiving a palliative approach resulted in comparable admission costings (AU$11 621 [IQR = AU$4705-AU$32 457] and AU$11 466 [IQR = AU$4973-AU$25 614]).

CONCLUSION

A palliative approach in terminal CHF admission may improve quality at the end of life and decrease costs associated with care.

Hospital-service use in the last year of life by patients aged ⩾60 years who died of heart failure or cardiomyopathy: A retrospective linked data study

BACKGROUND

Understanding patterns of health care use in the last year of life is critical in health services planning.

AIM

To describe hospital-based service and palliative care use in hospital in the year preceding death for patients who died of heart failure or cardiomyopathy in Queensland from 2008 to 2018 and had at least one hospitalisation in the year preceding death.

DESIGN

A retrospective data linkage study was conducted using administrative health data relating to hospitalisations, emergency department visits and deaths.

PARTICIPANTS AND SETTING

Participants included were those aged ⩾60 years, had a hospitalisation in their last year of life and died of heart failure or cardiomyopathy in Queensland, Australia.

RESULTS

Of the 4697 participants, there were 25,583 hospital admissions. Three quarters (n = 3420, 73%) of participants were aged ⩾80 years and over half died in hospital (n = 2886, 61%). The median number of hospital admissions in the last year of life was 3 (interquartile range [IQR] 2-5). The care type was recorded as 'acute' for 89% (n = 22,729) of hospital admissions, and few (n = 853, 3%) hospital admissions had a care type recorded as 'palliative.' Of the 4697 participants, 3458 had emergency department visit(s), presenting 10,330 times collectively.

CONCLUSION

In this study, patients who died of heart failure or cardiomyopathy were predominantly aged ⩾80 years and over half died in hospital. These patients experienced repeat acute hospitalisations in the year preceding death. Improving timely access to palliative care services in the outpatient or community setting is needed for patients with heart failure.

Effectiveness of transmural team-based palliative care in prevention of hospitalizations in patients at the end of life: A systematic review and meta-analysis

BACKGROUND

Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited.

AIM

To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently.

RESULTS

About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34-0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07-0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26-3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23-18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time.

CONCLUSION

Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.

Caring for Patients in Need of Palliative Care: Is This a Mission for Acute Care Hospitals? Key Questions for Healthcare Professionals

The prevalence of patients affected by end-stage diseases or advanced cancer is increasing due to an aging population and progression in medicine and public healthcare. The burden of symptoms these people suffer in the last months of life often forces them to seek aid in an emergency department. In developed countries, acute care hospital-based services are often better designed to treat acute clinical conditions than to manage the needs of patients with serious chronic diseases. Thus, the palliative care (PC) population poses very real clinical challenges to healthcare professionals who care for them in hospital settings. The authors have formulated four key questions (who, why, when, and how) to address in order to identify a model for providing the best care for these PC patients. The questions are related to: (1) defining people living with serious chronic diseases; (2) managing the challenge of unplanned hospital admission of these people; (3) identifying PC patients among people with serious chronic diseases; and (4) determining the appropriate work of caring for this inpatient PC population. Clinicians need the knowledge, tools, and services to care for these PC patients, and acute care hospitals should plan the work of caring for these inpatients.

Health expenditures after first hospital admission for heart failure in Nova Scotia, Canada: a retrospective cohort study

BACKGROUND

Although the frequency of heart failure makes it among the costliest of illnesses, there are scant Canadian data on annual costs of treatment or the costs as the condition advances. Our objective was to estimate mean prevalence- and incidence-based direct medical costs among older adults discharged alive after a first hospital admission for heart failure.

METHODS

We conducted a retrospective cohort study using population-based administrative health databases for Nova Scotia. The cohort comprised persons 50 years of age or older with an incident hospital admission for heart failure between 2009 and 2012. We considered the costs (expressed as 2020 Canadian dollars) of hospital admissions, physician visits and, for patients 65 years of age or older, outpatient cardiac medications. We estimated costs for calendar years, longitudinally and in the last 2 years of life. We analyzed costs from the perspective of a third-party public payer.

RESULTS

The cohort consisted of 3327 patients (mean age 77.6 yr; 1605 [48.2%] women). Median survival was 2.5 and 2.2 years among men and women, respectively. Annual prevalence-based costs were about $7100. Mean incidence-based costs ranged between $65 000 and $164 000 in the year after diagnosis and decreased by 90% subsequently. Costs were 4 to 7 times higher in the year before death than in the period from 1 to 2 years before death.

INTERPRETATION

The direct medical costs of treating patients with heart failure in Nova Scotia displayed a reverse J shape, with costs highest after diagnosis, declining subsequently and then increasing during the final year of life. Strategies designed to improve the quality of care immediately after diagnosis and during more advanced stages of disease might reduce these costs.

Rethinking the Meaning of Palliation in Heart Failure

PURPOSE OF REVIEW

Palliative care follows a philosophy of care that focuses upon the quality of life in patients with chronic or life-threatening illness. It also focuses upon the needs of their families which is a wider scope of care. Cardiovascular disease, and specifically heart failure, affects millions of patients and family members who have a symptom burden that exceeds that of many cancers and other chronic diseases.

RECENTLY FINDINGS

Historically palliative care has been viewed as an alternative to curative therapies, but over time, it is now recognized that it should be implemented earlier in the course of chronic diseases. Although non-oncologic patients now comprise over half of the patient seen by palliative care, patients with cardiovascular disease are still not being referred to palliative care. Palliative care goes beyond advance directives and end of life planning. There is a need to continue to expand the view of palliative care to encompass interventions that help improve the overall health of these patients, including their psychosocial well-being and quality of life. The collection of papers in this journal provides insight into the breadth of palliative care for patients with heart failure and other cardiovascular diseases.

Life and priorities before death: A narrative inquiry of uncertainty and end of life in people with heart failure and their family members

BACKGROUND

Most patients with advanced heart failure are ill-prepared and poorly supported during the end of life. To date, research has focused primarily on generalized patient accounts of the management or self-care phase of the syndrome. Little research has examined the end of life in depth or from the perspectives of family members.

AIMS

The purpose of this study is to describe how people diagnosed with heart failure and their family members describe uncertainty related to impending death.

METHODS AND RESULTS

A narrative inquiry was undertaken using a social constructionist perspective. Twenty participants took part in over 60 interviews: 12 participants with heart failure (eight male and four female; mean = 67.3 years) and eight family members (mean = 61.6 years) engaged in two in-depth interviews, approximately 3-4 months apart, followed by a telephone follow-up 2-3 months later. Six key themes/storylines were identified. These included: prognosis messages received from physicians; whenever I die, I die; loss isn't new to me but … ; carrying on amidst the fragility of life; ultimately living not knowing; and the need to prepare.

CONCLUSION

The six key storylines of death and dying with advanced heart failure were consistent for both patients and family members. There was a desire for better communication with physicians. Many participants were critical of how the prognosis of advanced heart failure was communicated to them, even if they anticipated the news. Participants wanted frank, open conversations with their healthcare providers that both acknowledged that they were at end of life but did not remove all hope.

Optimising compassionate nursing care at the end of life in hospital settings

BACKGROUND

An urgent need to improve palliative care in hospital has been identified. Moreover, service users consistently report care delivered by nurses in hospital as lacking compassion. Compassion is a fundamental component of nursing care, and promoting compassionate care has been identified as a policy priority in many countries. To help address this within the hospital context, we recently completed research exploring bereaved family experiences of good end of life care in hospital. We found that family accounts of good care aligned with Nolan and Dewar's compassionate care framework and subsequently extended the framework to the bi-cultural context of Aotearoa, New Zealand.

AIMS AND OBJECTIVES

In this discussion paper, we explore synergies between our newly developed Kapakapa Manawa Framework: a bi-cultural approach to providing compassionate care at the end of life and the Fundamentals of Care. We argue that our framework can be used to support the implementation of the relational component of the Fundamentals of Care and the delivery of compassionate nursing practice in hospitals in Aotearoa, New Zealand.

DESIGN

Discussion paper.

METHODS

Review of relevant literature and construction of two vignettes describing good end of life care from the perspectives of bereaved family-one Māori and one non-Māori. The vignettes provide practical examples of how the values of the Kapakapa Manawa Framework can be enacted by nurses to provide compassionate care in alignment with the relationship component of the Fundamentals of Care.

CONCLUSIONS

Whilst the Kapakapa Manawa bi-cultural compassionate care framework has grown out of research conducted with people nearing the end of their lives, it has the potential to improve nursing care for all hospital inpatients.

RELEVANCE TO CLINICAL PRACTICE

Addressing the wider policy and health system factors detailed in the Fundamentals of Care will support its implementation in the clinical setting.