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Johnson MJ, Rutterford L, Sunny A, Pask S, de Wolf-Linder S, Murtagh FEM, Ramsenthaler C. Benefits of specialist palliative care by identifying active ingredients of service composition, structure, and delivery model: A systematic review with meta-analysis and meta-regression. PLoS Med 2024; 21:e1004436. [PMID: 39093900 PMCID: PMC11329153 DOI: 10.1371/journal.pmed.1004436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 08/16/2024] [Accepted: 06/28/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Specialist palliative care (SPC) services address the needs of people with advanced illness. Meta-analyses to date have been challenged by heterogeneity in SPC service models and outcome measures and have failed to produce an overall effect. The best service models are unknown. We aimed to estimate the summary effect of SPC across settings on quality of life and emotional wellbeing and identify the optimum service delivery model. METHODS AND FINDINGS We conducted a systematic review with meta-analysis and meta-regression. Databases (Cochrane, MEDLINE, CINAHL, ICTRP, clinicaltrials.gov) were searched (January 1, 2000; December 28, 2023), supplemented with further hand searches (i.e., conference abstracts). Two researchers independently screened identified studies. We included randomized controlled trials (RCTs) testing SPC intervention versus usual care in adults with life-limiting disease and including patient or proxy reported outcomes as primary or secondary endpoints. The meta-analysis used, to our knowledge, novel methodology to convert outcomes into minimally clinically important difference (MID) units and the number needed to treat (NNT). Bias/quality was assessed via the Cochrane Risk of Bias 2 tool and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. Random-effects meta-analyses and meta-regressions were used to synthesize endpoints between 2 weeks and 12 months for effect on quality of life and emotional wellbeing expressed and combined in units of MID. From 42,787 records, 39 international RCTs (n = 38 from high- and middle-income countries) were included. For quality of life (33 trials) and emotional wellbeing (22 trials), statistically and clinically significant benefit was seen from 3 months' follow-up for quality of life, standardized mean difference (SMD in MID units) effect size of 0.40 at 13 to 36 weeks, 95% confidence interval (CI) [0.21, 0.59], p < 0.001, I2 = 60%). For quality of life at 13 to 36 weeks, 13% of the SPC intervention group experienced an effect of at least 1 MID unit change (relative risk (RR) = 1.13, 95% CI [1.06, 1.20], p < 0.001, I2 = 0%). For emotional wellbeing, 16% experienced an effect of at least 1 MID unit change at 13 to 36 weeks (95% CI [1.08, 1.24], p < 0.001, I2 = 0%). For quality of life, the NNT improved from 69 to 15; for emotional wellbeing from 46 to 28, from 2 weeks and 3 months, respectively. Higher effect sizes were associated with multidisciplinary and multicomponent interventions, across settings. Sensitivity analyses using robust MID estimates showed substantial (quality of life) and moderate (emotional wellbeing) benefits, and lower number-needed-to-treat, even with shorter follow-up. As the main limitation, MID effect sizes may be biased by relying on derivation in non-palliative care samples. CONCLUSIONS Using, to our knowledge, novel methods to combine different outcomes, we found clear evidence of moderate overall effect size for both quality of life and emotional wellbeing benefits from SPC, regardless of underlying condition, with multidisciplinary, multicomponent, and multi-setting models being most effective. Our data seriously challenge the current practice of referral to SPC close to death. Policy and service commissioning should drive needs-based referral at least 3 to 6 months before death as the optimal standard of care.
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Affiliation(s)
- Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | | | - Anisha Sunny
- School of Psychology and Social Work, Faculty of Health Sciences, University of Hull, Hull, United Kingdom
| | - Sophie Pask
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Susanne de Wolf-Linder
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
- School of Health Professions, Institute of Health Sciences, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Christina Ramsenthaler
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
- School of Health Professions, Institute of Health Sciences, Zurich University of Applied Sciences, Winterthur, Switzerland
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Mallon T, Schulze J, Dams J, Weber J, Asendorf T, Böttcher S, Sekanina U, Schade F, Schneider N, Freitag M, Müller C, König HH, Nauck F, Friede T, Scherer M, Marx G. Evaluating palliative care case conferences in primary care for patients with advanced non-malignant chronic conditions: a cluster-randomised controlled trial (KOPAL). Age Ageing 2024; 53:afae100. [PMID: 38783755 PMCID: PMC11116821 DOI: 10.1093/ageing/afae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs. OBJECTIVE To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC. METHODS A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale. RESULTS A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51). CONCLUSIONS The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.
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Affiliation(s)
- Tina Mallon
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Josefine Schulze
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Judith Dams
- Department of Health Economics and Health Care Research, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Jan Weber
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Centre Göttingen, Humboldtallee 32, 37073 Göttingen, Germany
| | - Silke Böttcher
- Division of General Practice, Carl von Ossietzky University of Oldenburg, Ammerlaender Heerstraße 114-118, 26129 Oldenburg, Germany
| | - Uta Sekanina
- Department of General Practice, University Medical Centre Göttingen, Humboldtallee 38, 37073 Göttingen, Germany
| | - Franziska Schade
- Department of Palliative Medicine, University Medical Centre Göttingen, Von-Siebold-Str. 3, 37075 Göttingen and Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Nils Schneider
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Michael Freitag
- Division of General Practice, Carl von Ossietzky University of Oldenburg, Ammerlaender Heerstraße 114-118, 26129 Oldenburg, Germany
| | - Christiane Müller
- Department of General Practice, University Medical Centre Göttingen, Humboldtallee 38, 37073 Göttingen, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Care Research, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, University Medical Centre Göttingen, Von-Siebold-Str. 3, 37075 Göttingen, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Centre Göttingen, Humboldtallee 32, 37073 Göttingen, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Gabriella Marx
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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DeGroot L, Pavlovic N, Perrin N, Gilotra NA, Miller H, Denfeld QE, McIlvennan CK, Dy SM, Davidson PM, Szanton SL, Abshire Saylor M. The Association of Unmet Palliative Care Needs and Physical Frailty With Clinical Outcomes: A Prospective Study of Adults With Heart Failure. J Cardiovasc Nurs 2024:00005082-990000000-00185. [PMID: 38635901 DOI: 10.1097/jcn.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND People with heart failure, particularly those who are physically frail, experience complex needs that can be addressed by palliative care (PC). However, we have a limited understanding of how the intersection of unmet PC needs and physical frailty contributes to health-related quality of life (HRQOL) and risk for hospitalization or mortality. OBJECTIVE In this study, we sought to examine the association of unmet PC needs and physical frailty with clinical outcomes (baseline HRQOL and hospitalizations or mortality at 6 months). METHODS We recruited a convenience sample of community-dwelling persons with heart failure from an urban hospital system who were older than 50 years and hospitalized in the last year. We measured physical frailty using the FRAIL scale (nonfrail, 0-2; frail, 3-5), PC needs using the Integrated Palliative Outcome Scale (range, 0-58; higher scores indicating higher needs), and HRQOL using the Kansas City Cardiomyopathy Questionnaire (range, 0-100; higher scores indicate higher HRQOL). We performed multivariable linear regression to test the relationships between physical frailty, PC needs, and HRQOL, and multivariable logistic regression for associations with all-cause 6-month hospitalization or mortality. We also performed an exploratory analysis of 4 PC needs/frailty groups (high PC needs/frail, high PC needs/nonfrail, low PC needs/frail, low PC needs/nonfrail) with outcomes. RESULTS In our overall sample (n = 298), mean (SD) age was 68 (9.8) years, 37% were women (n = 108), 28% identified as Black/African American (n = 84), and 65% had heart failure with preserved ejection fraction (n = 194). Mean PC needs score was 19.7, and frail participants (n = 130, 44%) had a significantly higher mean PC needs score than nonfrail participants (P < .001). Those with higher PC needs (Integrated Palliative Care Outcome Scale ≥ 20) had significantly worse HRQOL (P < .001) and increased odds of hospitalization or mortality (odds ratio, 2.5; P < .01) compared with those with lower PC needs, adjusting for covariates. Physically frail participants had significantly worse HRQOL (P < .001) and higher odds of hospitalization or mortality at 6 months (odds ratio, 2.6; P < .01) than nonfrail participants, adjusting for covariates. In an exploratory analysis, physically frail participants with high PC needs had the lowest HRQOL score, with an average score of 28.6 points lower (P < .001) and 4.6 times higher odds of hospitalization or mortality (95% confidence interval, 2.03-10.43; P < .001) than low-needs/nonfrail participants. CONCLUSION Higher unmet PC needs and physical frailty, separately and in combination, were associated with lower HRQOL and higher odds of hospitalization or mortality. Self-reported PC needs and physical frailty assessment in clinical settings may improve identification of patients at the highest risk for poor HRQOL and hospitalization or mortality amenable to PC intervention.
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Alnajar M, Darawad M, Khater W, Alshahwan R, Mosleh S, Nofal B, Abdalrahim M. Exploring Palliative Care Needs Among Patients With Cancer and Non-Cancer Serious Chronic Diseases: A Comparison Study. Am J Hosp Palliat Care 2024:10499091241235920. [PMID: 38386721 DOI: 10.1177/10499091241235920] [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: 02/24/2024] Open
Abstract
BACKGROUND Palliative care (PC) is integral to improving the quality of life and mitigating suffering for individuals with serious illnesses. This interdisciplinary-led study aims to comprehensively evaluate the prevalence of distressing problems and unmet needs among both cancer and non-cancer chronic disease patients and explore their need for PC. METHODS A cross-sectional, comparative, and multicenter design was conducted, involving 458 patients from eight hospitals, utilizing a self-reported Problems and Needs in Palliative Care-sv questionnaire. RESULTS The study included 276 (60.3%) patients with cancer and 182 (39.7%) with non-cancer chronic diseases. Most were 45-64 years old (n = 216, 47.2%). Patients with cancer reported a higher prevalence of physical symptoms, notably pain (n = 240, 87%) and anorexia (n = 192, 69.6%), while non-cancer patients faced more social challenges, including issues in companion relationships (n = 77, 42.3%) and discussing their disease with life companion (n = 78, 42.9%). Unmet needs were prevalent in both groups, with cancer patients having an average of 75.6% (n = 120) unmet needs, predominantly in the information (n = 145, 91.75%) and spiritual domains (n = 123, 77.8%). Non-cancer patients emphasized financial (n = 71, 66.6%) and autonomy (n = 59, 55.0%) problems. Moreover, patients in both groups with severe Charlson Comorbidity Index scores demonstrated significantly higher PC needs across all health domains. CONCLUSION The study highlights the universal demand for comprehensive PC for patients with both cancer and non-cancer chronic diseases. The findings underscore the need for enhanced PC provision, especially for patients with multiple comorbidities. Further research is needed to comprehensively address psychological, social, and spiritual problems in both patient groups.
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Affiliation(s)
- Malek Alnajar
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Muhammad Darawad
- School of Nursing, The University of Jordan, Amman, Jordan
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
| | - Wejdan Khater
- Department of Adults Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Rashed Alshahwan
- Department of General Surgery, Jordanian Royal Medical Services (JRMS), Amman, Jordan
| | - Sultan Mosleh
- Faculty of Nursing, Mutah University, Mu'tah, Jordan
| | - Basema Nofal
- Faculty of Nursing, Al-Zaytoonah University of Jordan, Amman, Jordan
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Bekelman DB, Feser W, Morgan B, Welsh CH, Parsons EC, Paden G, Baron A, Hattler B, McBryde C, Cheng A, Lange AV, Au DH. Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease: The ADAPT Randomized Clinical Trial. JAMA 2024; 331:212-223. [PMID: 38227034 PMCID: PMC10792473 DOI: 10.1001/jama.2023.24035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 11/01/2023] [Indexed: 01/17/2024]
Abstract
Importance Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life. Objective Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care. Design, Setting, and Participants Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated. Intervention The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health. Main Outcomes and Measures The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change ≥4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms. Results Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months. Conclusions and Relevance For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care. Trial Registration ClinicalTrials.gov Identifier: NCT02713347.
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Affiliation(s)
- David B. Bekelman
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - William Feser
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora
| | - Brianne Morgan
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
| | - Carolyn H. Welsh
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Elizabeth C. Parsons
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
| | - Grady Paden
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Anna Baron
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora
| | - Brack Hattler
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Connor McBryde
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Andrew Cheng
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Allison V. Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - David H. Au
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
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DeGroot L, Pavlovic N, Perrin N, Gilotra NA, Dy SM, Davidson PM, Szanton SL, Saylor MA. Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure. J Pain Symptom Manage 2023; 65:500-509. [PMID: 36736499 PMCID: PMC10192105 DOI: 10.1016/j.jpainsymman.2023.01.016] [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: 10/10/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 02/03/2023]
Abstract
CONTEXT Physical frailty is emerging as a potential "trigger" for palliative care (PC) consultation, but the PC needs of physically frail persons with heart failure (HF) in the outpatient setting have not been well described. OBJECTIVES This study describes the PC needs of community dwelling, physically frail persons with HF. METHODS We included persons with HF ≥50 years old who experienced ≥1 hospitalization in the prior year and excluded those with moderate/severe cognitive impairment, hospice patients, or non-English speaking persons. Measures included the FRAIL scale (0-5: 0 = robust, 1-2 = prefrail, 3-5 = frail) and the Integrated Palliative Outcome Scale (IPOS) (17 items, score 0-68; higher score = higher PC needs). Multiple linear regression tested the association between frailty group and palliative care needs. RESULTS Participants (N = 286) had a mean age of 68 (range 50-92) were majority male (63%) and White (68%) and averaged two hospitalizations annually. Most were physically frail (44%) or prefrail (41%). Mean PC needs (IPOS) score was 19.7 (range 0-58). On average, participants reported 5.86 (SD 4.28) PC needs affecting them moderately, severely, or overwhelmingly in the last week. Patient-perceived family/friend anxiety (58%) weakness/lack of energy (58%), and shortness of breath (47%) were the most prevalent needs. Frail participants had higher mean PC needs score (26) than prefrail (16, P < 0.001) or robust participants (11, P < 0.001). Frail participants experienced an average of 8.32 (SD 3.72) moderate/severe/overwhelming needs compared to prefrail (4.56, SD 3.77) and robust (2.39, SD 2.91) participants (P < 0.001). Frail participants reported higher prevalence of weakness/lack of energy (83%), shortness of breath (66%), and family/friend anxiety (69%) than prefrail (48%, 39%, 54%) or robust (13%, 14%, 35%) participants (P < 0.001). CONCLUSION Physically frail people with HF have higher unmet PC needs than those who are nonfrail. Implementing PC needs and frailty assessments may help identify vulnerable patients with unmet needs requiring further assessment and follow-up.
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Affiliation(s)
- Lyndsay DeGroot
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA.
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Johns Hopkins University School of Medicine (N.A.G), Baltimore, Maryland, USA
| | - Sydney M Dy
- Johns Hopkins University School of Public Health (S.M.D), Baltimore, Maryland, USA
| | | | - Sarah L Szanton
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Martha Abshire Saylor
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
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7
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Chyr LC, Sauers EG, Dy SM, Waldfogel JM. The Application of Minimal Clinically Important Differences in Palliative Research: Interpretation of Results of a Systematic Review. J Pain Symptom Manage 2022; 64:e363-e371. [PMID: 36002121 DOI: 10.1016/j.jpainsymman.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT Interpreting clinical meaningfulness of patient reported outcomes (PROs) in palliative care research is key in evidence-based practice. Minimal clinically important differences (MCIDs) can help interpret whether changes in PROs are meaningful to patients. OBJECTIVE To examine use of MCIDs in a recent systematic review on integrating palliative care into ambulatory care for U.S. adults with noncancer serious chronic illness and their effect on interpretation of key PROs. METHODS Paired investigators abstracted MCIDs for each PRO in the systematic review from PubMed, tool specific websites, and Google Scholar. Investigators compared findings and resolved differences through consensus. MCIDs were interpreted alongside results from meta-analyses or individual studies to draw conclusions on effectiveness of interventions. RESULTS MCIDs could be identified for 10 of 23 instruments affecting seven of nine outcomes. The most notable effect was for depressive symptoms, where three trials reported statistically significant differences that were not clinically meaningful based on available MCIDs. Although differences in statistical significance and MCIDs were noted for other outcomes, they were accounted for in meta-analyses or affected a minimal number of studies within the outcome category. CONCLUSIONS Incorporating MCIDs affected the interpretation of almost all PROs in the systematic review. MCIDs are important measures of clinical meaningfulness for the interpretation of palliative care research involving PROs. Researchers should consider using instruments with well-established MCIDs and incorporate MCIDs, when available, in study design and interpretation.
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Affiliation(s)
- Linda C Chyr
- Department of Health Policy and Management (L.C.C., S.M.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Elizabeth G Sauers
- Department of Pharmacy (E.G.S.), Massachusetts General Hospital, Boston, USA
| | - Sydney M Dy
- Department of Health Policy and Management (L.C.C., S.M.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Julie M Waldfogel
- Department of Pharmacy (J.M.W.), The Johns Hopkins Hospital, Baltimore, USA
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8
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Feder SL. Commentary on primary palliative care for heart failure provided within ambulatory cardiology: A randomized pilot trial. Heart Lung 2022; 56:183-184. [PMID: 35965254 DOI: 10.1016/j.hrtlng.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Shelli L Feder
- Yale School of Nursing, Orange, CT, United States; VA Connecticut Healthcare System, West Haven, CT, United States.
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