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Feder SL, Han L, Zhan Y, Abel EA, Akgün KM, Fried T, Ersek M, Redeker NS. Variation in Specialist Palliative Care Reach and Associated Factors Among People With Advanced Heart Failure in the Department of Veterans Affairs. J Pain Symptom Manage 2024; 68:22-31.e1. [PMID: 38561132 PMCID: PMC11168897 DOI: 10.1016/j.jpainsymman.2024.03.022] [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: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Abstract
CONTEXT Clinical practice guidelines recommend palliative care for people with advanced heart failure (aHF), yet it remains underutilized. OBJECTIVES We examined medical center variation in specialist palliative care (SPC) and identified factors associated with variation among people with aHF. METHODS We conducted a retrospective cohort study of 21,654 people with aHF who received healthcare in 83 Veterans Affairs Medical Centers (VAMCs) from 2018-2020. We defined aHF with ICD-9/10 codes and hospitalizations. We used random intercept multilevel logistic regression to derive SPC reach (i.e., predicted probability) for each VAMC adjusting for demographic and clinical characteristics. We then examined VAMC-level SPC delivery characteristics associated with predicted SPC reach including the availability of outpatient SPC (proportion of outpatient consultations), cardiology involvement (number of outpatient cardiology-initiated referrals), and earlier SPC (days from aHF identification to consultation). RESULTS Of the sample the mean age = 72.9+/-10.9 years, 97.9% were male, 61.6% were White, and 32.2% were Black. The predicted SPC reach varied substantially across VAMCs from 9% to 57% (mean: 28% [95% Confidence Interval: 25%-30%]). Only the availability of outpatient SPC was independently associated with higher SPC reach. VAMCs, in which outpatient delivery made up the greatest share of SPC consultations (9% or higher) had 11% higher rates of SPC reach relative to VAMCs with a lower proportion of outpatient SPC. CONCLUSION SPC reach varies widely across VAMCs for people with aHF. Outpatient palliative is common among high-reach VAMCs but its role in reach warrants further investigation. Strategies used by high-reach VAMCs may be potential targets to test for implementation and dissemination.
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Affiliation(s)
- Shelli L Feder
- Yale School of Nursing(S.L.F., Y.Z.), Orange, Connecticut, USA; VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA.
| | - Ling Han
- VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA; Yale Program on Aging(L.H., K.M.A., T.F.), New Haven, Connecticut, USA
| | - Yan Zhan
- Yale School of Nursing(S.L.F., Y.Z.), Orange, Connecticut, USA
| | - Erica A Abel
- VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA; Yale Program on Aging(L.H., K.M.A., T.F.), New Haven, Connecticut, USA
| | - Terri Fried
- VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA; Yale Program on Aging(L.H., K.M.A., T.F.), New Haven, Connecticut, USA; Yale School of Medicine(T.F.), Department of Internal Medicine, New Haven, CT, USA
| | - Mary Ersek
- Veteran Experience Center(M.E.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennysylvania, USA; Leonard Davis Institute(M.E.), University of Pennsylvania, Philadelphia, Pennysylvania, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing(N.S.R.), Storrs, Connecticut, USA
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Feder SL, Zhan Y, Abel EA, Smith D, Ersek M, Fried T, Redeker NS, Akgün KM. Validation of Electronic Health Record-Based Algorithms to Identify Specialist Palliative Care Within the Department of Veterans Affairs. J Pain Symptom Manage 2023; 66:e475-e483. [PMID: 37364737 PMCID: PMC10527602 DOI: 10.1016/j.jpainsymman.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND The measurement of specialist palliative care (SPC) across Department of Veterans Affairs (VA) facilities relies on algorithms applied to administrative databases. However, the validity of these algorithms has not been systematically assessed. MEASURES In a cohort of people with heart failure identified by ICD 9/10 codes, we validated the performance of algorithms to identify SPC consultation in administrative data and differentiate outpatient from inpatient encounters. INTERVENTION We derived separate samples of people by receipt of SPC using combinations of stop codes signifying specific clinics, current procedural terminology (CPT), a variable representing encounter location, and ICD-9/ICD-10 codes for SPC. We calculated sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for each algorithm using chart review as the reference standard. OUTCOMES Among 200 people who did and did not receive SPC (mean age = 73.9 years (standard deviation [SD] = 11.5), 98% male, 73% White), the validity of the stop code plus CPT algorithm to identify any SPC consultation was: Sensitivity = 0.89 (95% Confidence Interval [CI] 0.82-0.94), Specificity = 1.0 [0.96-1.0], PPV = 1.0 [0.96-1.0], NPV = 0.93 [0.86-0.97]. The addition of ICD codes increased sensitivity but decreased specificity. Among 200 people who received SPC (mean age = 74.2 years [SD = 11.8], 99% male, 71% White), algorithm performance in differentiating outpatient from inpatient encounters was: Sensitivity = 0.95 (0.88-0.99), Specificity = 0.81 (0.72-0.87), PPV = 0.38 (0.29-0.49), and NPV = 0.99 (0.95-1.0). Adding encounter location improved the sensitivity and specificity of this algorithm. CONCLUSIONS VA algorithms are highly sensitive and specific in identifying SPC and in differentiating outpatient from inpatient encounters. These algorithms can be used with confidence to measure SPC in quality improvement and research across the VA.
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Affiliation(s)
- Shelli L Feder
- Yale School of Nursing (S.L.F., Y.Z.), Orange, Connecticut, USA; VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA.
| | - Yan Zhan
- Yale School of Nursing (S.L.F., Y.Z.), Orange, Connecticut, USA
| | - Erica A Abel
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA
| | - Dawn Smith
- Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center (D.S., M.E.), Philadelphia, Pennsylvania, USA
| | - Mary Ersek
- Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center (D.S., M.E.), Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing (M.E.), Philadelphia, Pennsylvania, USA
| | - Terri Fried
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA; Yale Program on Aging (T.F.), New Haven, Connecticut, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing (N.S.R.), Storrs, Connecticut, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA
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Feder SL, Murphy TE, Abel EA, Akgün KM, Warraich HJ, Ersek M, Fried T, Redeker NS. Incidence and Trends in the Use of Palliative Care among Patients with Reduced, Middle-Range, and Preserved Ejection Fraction Heart Failure. J Palliat Med 2022; 25:1774-1781. [PMID: 35763838 PMCID: PMC9784595 DOI: 10.1089/jpm.2022.0093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2022] [Indexed: 01/04/2023] Open
Abstract
Background: Clinical practice guidelines recommend integrating palliative care (PC) into the care of patients with heart failure (HF) to address their many palliative needs. However, the incidence rates of PC use among HF subtypes are unknown. Methods: We conducted a retrospective cohort study of patients with the following HF subtypes in the Department of Veterans Affairs: reduced ejection fraction (HFrEF), mid-range ejection fraction (HFmEF), and preserved ejection fraction (HFpEF). Patients were included at the time of HF diagnosis from 2011 to 2015 and followed until a minimum of five years or death. Incidence rates of receipt of PC (primary outcome) were calculated using generalized estimating equations. We evaluated the time to incident PC by HF subtype with Kaplan-Meier analyses and with adjusted restricted mean survival time. Results: Of the 113,555 patients, 69% were ≥65 years, 98% were male, 73% White, and 18% Black; 58% had HFrEF, 7% HFmEF, and 34% HFpEF. Twenty percent received PC during follow-up, and 66% died. Adjusted PC incidence rates were higher among patients with HFrEF (47 per 1000 person-years, confidence interval [95% CI] 43-52) than for HFmEF and HFpEF (42 per 1000 person-years, CI 38-47 for both). Restricting follow-up to five years, patients with HFrEF received PC six weeks earlier than patients with HFpEF. There was no significant difference in time to PC between patients with HFmEF versus HFpEF. Conclusion: About 1 in 20 patients with HFrEF and 1 in 25 patients with HFmEF and HFpEF receive PC annually. Patients with HFrEF receive PC sooner than patients with HFmEF and HFpEF.
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Affiliation(s)
- Shelli L. Feder
- Yale School of Nursing, West Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | | | - Erica A. Abel
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Kathleen M. Akgün
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Terri Fried
- Yale Program on Aging, New Haven, Connecticut, USA
| | - Nancy S. Redeker
- Yale School of Nursing, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Sullivan DR, Teno JM, Reinke LF. Evolution of Palliative Care in the Department of Veterans Affairs: Lessons from an Integrated Health Care Model. J Palliat Med 2021; 25:15-20. [PMID: 34665652 DOI: 10.1089/jpm.2021.0246] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Palliative care (PC) is beneficial, however, in many settings it is under-resourced and unable to consistently meet the needs of patients and their families. A lack of national health policy support for PC contributes to underutilization and the low value care experienced by many patients with serious illness at the end of life. Through a series of transformative health care structure and process improvements including developing robust initiatives and promoting institutional culture change, the Department of Veterans Affairs (VA) has significantly improved the quality of PC among veterans. VA's strategic simultaneous top-down and bottom-up approach to develop programs, policies, and initiatives provides important perspectives and deserves attention toward advancing PC in the broader U.S. health care system. Although opportunities for improvement exist, the comprehensive framework within VA should help inform the future of program development and serve as a model for integrated and accountable care organizations to emulate.
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Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA.,Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, OHSU, Portland, Oregon, USA
| | - Lynn F Reinke
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington, USA.,Department of Biobehavioral Nursing and Health Systems, University of Washington, School of Medicine, Seattle, Washington, USA
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