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Abel AAI, Samuel NA, Cuthbert JJ, Brown OI, Pellicori P, Kazmi S, Cleland JGF, Johnson MJ, Clark AL. Hospital admissions in the last year of life of patients with heart failure. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:168-175. [PMID: 37553153 DOI: 10.1093/ehjqcco/qcad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/05/2023] [Accepted: 08/07/2023] [Indexed: 08/10/2023]
Abstract
AIM To explore the frequency, causes, and pattern of hospitalisation for patients with chronic heart failure (HF) in the 12 months preceding death. We also investigated cause of death. METHODS Patients referred to a secondary care HF clinic were routinely consented for follow-up between 2001 and 2020 and classified into three phenotypes: (i) HF with reduced ejection fraction (HFrEF), (ii) HF with preserved ejection fraction (HFpEF) with plasma N-terminal pro B-type natriuretic peptide (NT-proBNP) 125-399 ng L-1, and (iii) HFpEF with NT-proBNP ≥400 ng L-1. Hospital admissions in the last year of life were classified as: HF, other cardiovascular (CV), or non-cardiovascular (non-CV). The cause of death was systematically adjudicated. RESULTS A total of 4925 patients (38% women; median age at death 81 [75-87] years) had 9127 hospitalisations in the last year of life. The median number of hospitalisations was 2 (1-3) and total days spent in hospital was 12 (2-25). Out of the total, 83% of patients had ≥1 hospitalisation but only 20% had ≥1 HF hospitalisation; 24% had ≥1 CV hospitalisation; 70% had ≥1 non-CV hospitalisation. Heart failure hospitalisations were most common in patients with HFrEF, but in all groups, at least two thirds of admissions were for non-CV causes. There were 788 (16%) deaths due to progressive HF, of which 74% occurred in hospital. CONCLUSION For patients with chronic HF in the last year of life, most hospitalisations were for non-CV causes regardless of HF phenotype. Most patients had no HF hospitalisations in their last year of life. Most deaths were from causes other than progressive HF.
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Affiliation(s)
- Alexandra A I Abel
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston upon Hull, HU16 5JQ, UK
| | - Nathan A Samuel
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston upon Hull, HU16 5JQ, UK
| | - Joseph J Cuthbert
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston upon Hull, HU16 5JQ, UK
| | - Oliver I Brown
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston upon Hull, HU16 5JQ, UK
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Syed Kazmi
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston upon Hull, HU16 5JQ, UK
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, HU6 7RX, UK
| | - Andrew L Clark
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston upon Hull, HU16 5JQ, UK
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Atkinson C, Hughes S, Richards L, Sim VM, Phillips J, John IJ, Yousef Z. Palliation of heart failure: value-based supportive care. BMJ Support Palliat Care 2022:bmjspcare-2021-003378. [PMID: 35788466 DOI: 10.1136/bmjspcare-2021-003378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Heart failure (HF) is a prevalent condition associated with poor quality-of-life and high symptom burden. As patients reach ceilings of survival-extending interventions, their priorities may be more readily addressed through the support of palliative care services; however, the best model of care remains unestablished.We aimed to create and evaluate a cospeciality cross-boundary service model for patients with HF that better provides for their palliative care needs in the latter stages of life, while delivering a more cost-effective patient journey. METHODS In 2016, the Heart Failure Supportive Care Service (HFSCS) was established to provide patient-centred holistic support to patients with advanced HF. Patient experience questionnaires were developed and distributed in mid-2018 and end-of-2020. Indexed hospital admission data (in-patient bed days pre-referral/post-referral) were used allowing statistical comparisons by paired t-tests. RESULTS From 2016-2020, 236 patients were referred to the HFSCS. Overall, 75/118 questionnaires were returned. Patients felt that the HFSCS delivered compassionate care (84%) that improved symptoms and quality of life (80% and 65%). Introduction of the HFSCS resulted in a reduction in HF-related admissions: actual days 18.3 to 4 days (p<0.001), indexed days 0.05 to 0.032 days (p=0.03). Cost mapping revealed an estimated average saving of at least £10 218.36 per referral and a total estimated cost saving of approximately £2.4 million over 5 years. CONCLUSION This service demonstrates that a cospeciality cross-boundary method of care delivery successfully provides the benefits of palliative care to patients with HF in a value-based manner, while meeting the priorities of care that matter to patients most.
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Affiliation(s)
- Clea Atkinson
- Palliative and Supportive Care Department, Cardiff and Vale University Health Board, Cardiff, UK .,Palliative Care Department, Cardiff University School of Medicine, Cardiff, UK
| | - Sian Hughes
- Palliative and Supportive Care Department, Cardiff and Vale University Health Board, Cardiff, UK
| | - Len Richards
- Executive Team, Cardiff and Vale University Health Board, Cardiff, UK
| | - Victor Mf Sim
- Care of the Elderly Department, Cardiff and Vale University Health Board, Cardiff, UK
| | - Julie Phillips
- Cardiology Department, Cardiff and Vale University Health Board, Cardiff, UK
| | - Imogen J John
- Palliative and Supportive Care Department, Cardiff and Vale University Health Board, Cardiff, UK
| | - Zaheer Yousef
- Cardiology Department, Cardiff and Vale University Health Board, Cardiff, UK.,Cardiology Department, Cardiff University School of Medicine, Cardiff, UK
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Wolfe A, Watt CL, Downar J, Bush SH. Use and Discontinuation of Milrinone for Advanced Heart Failure in an Academic Palliative Care Unit: A Case Report and Discussion of Recommendations. J Pain Palliat Care Pharmacother 2022; 36:24-33. [PMID: 35234559 DOI: 10.1080/15360288.2022.2027058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The use of intravenous inotropic medications in advanced heart failure (HF) has been shown to improve symptoms and decrease hospitalizations, prompting support for their use as a palliative measure for symptom management. Recommendations regarding inotrope management and method of discontinuation at the end of life are not specifically detailed in the literature and current guidelines. This case report describes the use of milrinone in a patient with advanced HF during the terminal phase of illness in a non-monitored palliative care unit setting, including dose reduction and discontinuation of milrinone. Increased patient anxiety during the weaning process was managed with midazolam. The provision of individualized milrinone therapy in non-monitored palliative care settings is feasible and well-tolerated using the presented detailed recommendations for its use and administration, monitoring, dose reduction and discontinuation and proactive symptom management at the end of life. Further research is needed for the optimal management of terminally ill patients with advanced HF.Supplemental data for this article is available online at here. show.
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McConnell T, Diffin J, Fitzsimons D, Harrison C, Stone C, Reid J. Palliative care and heart failure: Can implementation science help where the evidence alone has failed? Eur J Cardiovasc Nurs 2019; 19:190-191. [DOI: 10.1177/1474515119894215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Masterson Creber R, Russell D, Dooley F, Jordan L, Baik D, Goyal P, Hummel S, Hummel EK, Bowles KH. Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure. ESC Heart Fail 2019; 6:371-378. [PMID: 30835970 PMCID: PMC6437549 DOI: 10.1002/ehf2.12398] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/23/2018] [Indexed: 01/14/2023] Open
Abstract
AIMS Estimating survival is challenging in the terminal phase of advanced heart failure. Patients, families, and health-care organizations would benefit from more reliable prognostic tools. The Palliative Performance Scale Version 2 (PPSv2) is a reliable and validated tool used to measure functional performance; higher scores indicate higher functionality. It has been widely used to estimate survival in patients with cancer but rarely used in patients with heart failure. The aim of this study was to identify prognostic cut-points of the PPSv2 for predicting survival among patients with heart failure receiving home hospice care. METHODS AND RESULTS This retrospective cohort study included 1114 adult patients with a primary diagnosis of heart failure from a not-for-profit hospice agency between January 2013 and May 2017. The primary outcome was survival time. A Cox proportional-hazards model and sensitivity analyses were used to examine the association between PPSv2 scores and survival time, controlling for demographic and clinical variables. Receiver operating characteristic curves were plotted to quantify the diagnostic performance of PPSv2 scores by survival time. Lower PPSv2 scores on admission to hospice were associated with decreased median (interquartile range, IQR) survival time [PPSv2 10 = 2 IQR: 1-5 days; PPSv2 20 = 3 IQR: 2-8 days] IQR: 55-207. The discrimination of the PPSv2 at baseline for predicting death was highest at 7 days [area under the curve (AUC) = 0.802], followed by an AUC of 0.774 at 14 days, an AUC of 0.736 at 30 days, and an AUC of 0.705 at 90 days. CONCLUSIONS The PPSv2 tool can be used by health-care providers for prognostication of hospice-enrolled patients with heart failure who are at high risk of near-term death. It has the greatest utility in patients who have the most functional impairment.
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Affiliation(s)
- Ruth Masterson Creber
- Division of Health Informatics, Department of Healthcare Policy and ResearchWeill Cornell Medicine425 East Street, Suite 301New YorkNY10065USA
| | - David Russell
- Visiting Nurse Service of New YorkNew YorkNY10021USA
- Appalachian State UniversityBooneNC28608USA
| | | | | | - Dawon Baik
- Columbia University School of NursingNew YorkNY10032USA
| | - Parag Goyal
- Department of MedicineWeill Cornell MedicineNew YorkNY10065USA
| | - Scott Hummel
- Department of MedicineUniversity of Michigan, Ann Arbor Veterans Affairs Health SystemAnn ArborMI48105USA
| | - Ellen K. Hummel
- Department of MedicineUniversity of Michigan, Ann Arbor Veterans Affairs Health SystemAnn ArborMI48105USA
| | - Kathryn H. Bowles
- University of Pennsylvania School of NursingPhiladelphiaPA19104USA
- Center for Home Care Policy and ResearchVisiting Nurse Service of New YorkNew YorkNY10021USA
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