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Palliative Care Consultations for Advanced Heart Failure Patients: Experience from a Safety-Net Hospital
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Journal of Cardiac Failure Vol. 24 No. 8S August 2018
249
250
Palliative Care Consultations for Advanced Heart Failure Patients: Experience from a Safety-Net Hospital Ahmed B. Alsalem1,2, Ziduo Zheng1, Yijian Huang1, Kathryn Norton2, Diane Wirth2, Ashima A. Lal1,2, Paul L. Desandre1,2, Marc D. Thames1,2, Modele O. Ogunniyi1,2; 1 Emory University, Atlanta, GA; 2Grady Memorial Hospital, Atlanta, GA Background: Traditionally, palliative care was thought to play a role when “end of life” measures are considered. This paradigm has shifted, with several studies showing the need for early palliative care and its positive impact on quality of life in patients with advanced heart failure (AHF). Palliative care should be provided early in the course of the disease trajectory and integrated with other disease modifying therapies. We sought to characterize the practice of palliative care consultations (PCC) for patients with AHF in a safety-net hospital. Methods: We conducted a retrospective chart review of all HF admissions from October 1, 2016 to September 30, 2017 and identified those who received PCC. Using a severity of illness (SOI) index, determined by the presence of comorbidities, we selected patients with major or extreme SOI. Patients were stratified by length of stay, ICU admission and costs of admission. Analysis was done using Chi-square or Fisher’s exact test as appropriate for categorical variables, or student’s t test for normally distributed continuous variables (p-level of < 0.05). Results: We analyzed a total of 786 admissions for HF with major or extreme SOI over the 1-year period. We identified 60 patients with a total of 94 admissions who received PCC and 520 HF patient without PCC (692 total admissions). In the PCC group, mean age was 65 years, 45% were females, and 92% were African Americans (Table 1). The PCC group was older, had higher SOI and higher cost per admission than the total HF group (Table 1). PCC was mostly utilized as an end of life measure with odds ratio of death/hospice of 17.1 (95% CI: 8.9-33.2) in the PCC group compared to patients without PCC, even when the ICU admission rate was the same between the two groups (Fig 1). Conclusions: PCC is being utilized late in the management of AHF patients, despite HF guidelines recommending early involvement for symptom management and advance care planning. Early PCC may allow for incorporation of palliative care services, thus improving the quality of life for patients with AHF. Table 1.
Trends in 30-day Outcomes Following Acute Heart Failure Hospitalization in an Electronic Health Records Database, 2012-2017 Ella Nkhoma1, Paul Kessler2, Maria Borentain2, Rosa Wang2, Mary M. DeSouza2; 1 Bristol-Myers Squibb, Pennington, NJ; 2Bristol-Myers Squibb, Lawrenceville Township, NJ Introduction: This study sought to examine recent trends of 30-day outcomes including readmission, mortality and prolonged length of stay (LOS) among patients hospitalized for acute heart failure (HF) and reduced ejection fraction. Methods: We identified patients hospitalized for HF with reduced ejection fraction (HFrEF, defined as a left ventricular EF 40%) between 2012 and 2017 in a large US electronic health record database. Thirty-day outcomes were HF-related readmission, all-cause mortality and index hospitalization with a LOS 4 days. We conducted trend analyses examining annual changes in incidence proportions over time using multinomial logistic regression and the Cochran-Armitage trend test. Results: A total of 107,016 patients with an acute HFrEF hospitalization were identified over the study period. The mean age was 69.5 years (SD=14.0) and 63.9% of patients were male. Overall, 12.5% and 10.3% of patients experienced 30-day HF-related readmission and all-cause death respectively. 79.5% had a LOS 4 days of the index hospitalization. Over the 6-year period, we observed a significant (defined as p< 0.05) decreasing trend in 30-day HF-related readmission over time (9.6% decrease) and a significantly increasing trend in LOS 4 days (6% increase). 30-day all-cause deaths did not change significantly over the study period. Additionally, there was also a decreasing trend in in-hospital mean estimated glomerular filtration rate (8.3% decrease) and changes in medication usage over time, including increasing administration of inotropic agents, especially milrinone and dobutamine which increased by 38.6% and 41.5%, respectively over the study period. Conclusions: In this large real world database, over a 6-year period we observed a reduction in 30-day HF-related readmission. We also observed an increase in the proportion of patients with LOS 4 days and an increase in use of inotropes over time.
251 Family Caregiver Strain and Likelihood of Heart Failure Patient Clinical Events: A Replication Study Julie T. Bidwell1, Christopher S. Lee2, Melinda K. Higgins1, Carolyn M. Reilly1, Patricia C. Clark3, Sandra B. Dunbar1; 1Emory University, Atlanta, GA; 2Boston College, Chestnut Hill, MA; 3Georgia State University, Atlanta, GA Introduction: Higher caregiver strain was identified as a predictor of lower patient clinical event-risk in a previous analysis of Italian heart failure (HF) patient-caregiver dyads. The purpose of this analysis was to determine whether this trade-off in patient and caregiver outcomes was culturally bound, or replicable in a North American sample. Hypothesis: We hypothesized that, similar to the Italian study, higher strain in North American caregivers would predict lower patient event-risk. Methods: This was a secondary analysis of data from a 3-arm (usual care, patient-family education, and family partnership intervention) randomized controlled trial to improve HF self-care. Data collection occurred pre-intervention and 4 and 8 months postintervention. Caregiver strain was measured pre-intervention using the 15-item Bakas Caregiving Outcomes Survey (BCOS: range 15-105, higher scores indicate more positive outcomes related to caregiving), and tertiles were used to divide caregivers into low, moderate, or high strain for analysis. Generalized linear regression was used to examine caregiver strain as a predictor of the likelihood of having any event (HF hospitalization, HF emergency room visit, or all-cause mortality) over time, controlling for intervention group and recent HF hospitalization (previous 4 months). Results: All patients (n=92) were NYHA Class II or III, with the majority being Class II (n=68, 73.9%). Patients and caregivers were in their mid-fifties on average (56.3§10.1 and 53.4§12.4 years, respectively) and racially diverse (n=58, 63.0% and n=59, 64.8% African American, respectively), with most patients being male (n=57, 62.0%) and most caregivers being female (n=75, 84.2%). The most common dyad type was spousal (n=40, 44.0%). Over the 8 months, 28 patients were hospitalized, 6 had an emergency room visit and 6 died. The average BCOS scores for the low, moderate, and high strain groups were 82.9§12.5 (range 66-105), 61.1§1.6 (range 60-65), and 52.1§7.4 (range 31-59), respectively. There was no difference in events by intervention group. High caregiver strain (as compared to low strain) was associated with 91.9% lower likelihood of the patient having an event over 8 months follow-up (OR=0.081, 95%CI=0.008-0.850, p=0.036). There was no significant difference in event-risk by moderate caregiver strain. Conclusions: Similar to previous findings in an Italian cohort, higher caregiver strain predicted lower HF patient clinical event-risk in this North American sample. Patient event-risk reductions may come with a cost for the family caregiver - a cost that has known sequelae (morbidity, mortality) and must be assessed and addressed.
252 Evaluation of Diuretics in Admitted Heart Failure Patients with Modification of Medication Order Entry Yekaterina Opsha, Rebeca Kane; Saint Barnabas Medical Center, Livingston, NJ Figure 1.
Journal of Cardiac Failure Vol. 24 No. 8S August 2018
249
250
Palliative Care Consultations for Advanced Heart Failure Patients: Experience from a Safety-Net Hospital Ahmed B. Alsalem1,2, Ziduo Zheng1, Yijian Huang1, Kathryn Norton2, Diane Wirth2, Ashima A. Lal1,2, Paul L. Desandre1,2, Marc D. Thames1,2, Modele O. Ogunniyi1,2; 1 Emory University, Atlanta, GA; 2Grady Memorial Hospital, Atlanta, GA Background: Traditionally, palliative care was thought to play a role when “end of life” measures are considered. This paradigm has shifted, with several studies showing the need for early palliative care and its positive impact on quality of life in patients with advanced heart failure (AHF). Palliative care should be provided early in the course of the disease trajectory and integrated with other disease modifying therapies. We sought to characterize the practice of palliative care consultations (PCC) for patients with AHF in a safety-net hospital. Methods: We conducted a retrospective chart review of all HF admissions from October 1, 2016 to September 30, 2017 and identified those who received PCC. Using a severity of illness (SOI) index, determined by the presence of comorbidities, we selected patients with major or extreme SOI. Patients were stratified by length of stay, ICU admission and costs of admission. Analysis was done using Chi-square or Fisher’s exact test as appropriate for categorical variables, or student’s t test for normally distributed continuous variables (p-level of < 0.05). Results: We analyzed a total of 786 admissions for HF with major or extreme SOI over the 1-year period. We identified 60 patients with a total of 94 admissions who received PCC and 520 HF patient without PCC (692 total admissions). In the PCC group, mean age was 65 years, 45% were females, and 92% were African Americans (Table 1). The PCC group was older, had higher SOI and higher cost per admission than the total HF group (Table 1). PCC was mostly utilized as an end of life measure with odds ratio of death/hospice of 17.1 (95% CI: 8.9-33.2) in the PCC group compared to patients without PCC, even when the ICU admission rate was the same between the two groups (Fig 1). Conclusions: PCC is being utilized late in the management of AHF patients, despite HF guidelines recommending early involvement for symptom management and advance care planning. Early PCC may allow for incorporation of palliative care services, thus improving the quality of life for patients with AHF. Table 1.
Trends in 30-day Outcomes Following Acute Heart Failure Hospitalization in an Electronic Health Records Database, 2012-2017 Ella Nkhoma1, Paul Kessler2, Maria Borentain2, Rosa Wang2, Mary M. DeSouza2; 1 Bristol-Myers Squibb, Pennington, NJ; 2Bristol-Myers Squibb, Lawrenceville Township, NJ Introduction: This study sought to examine recent trends of 30-day outcomes including readmission, mortality and prolonged length of stay (LOS) among patients hospitalized for acute heart failure (HF) and reduced ejection fraction. Methods: We identified patients hospitalized for HF with reduced ejection fraction (HFrEF, defined as a left ventricular EF 40%) between 2012 and 2017 in a large US electronic health record database. Thirty-day outcomes were HF-related readmission, all-cause mortality and index hospitalization with a LOS 4 days. We conducted trend analyses examining annual changes in incidence proportions over time using multinomial logistic regression and the Cochran-Armitage trend test. Results: A total of 107,016 patients with an acute HFrEF hospitalization were identified over the study period. The mean age was 69.5 years (SD=14.0) and 63.9% of patients were male. Overall, 12.5% and 10.3% of patients experienced 30-day HF-related readmission and all-cause death respectively. 79.5% had a LOS 4 days of the index hospitalization. Over the 6-year period, we observed a significant (defined as p< 0.05) decreasing trend in 30-day HF-related readmission over time (9.6% decrease) and a significantly increasing trend in LOS 4 days (6% increase). 30-day all-cause deaths did not change significantly over the study period. Additionally, there was also a decreasing trend in in-hospital mean estimated glomerular filtration rate (8.3% decrease) and changes in medication usage over time, including increasing administration of inotropic agents, especially milrinone and dobutamine which increased by 38.6% and 41.5%, respectively over the study period. Conclusions: In this large real world database, over a 6-year period we observed a reduction in 30-day HF-related readmission. We also observed an increase in the proportion of patients with LOS 4 days and an increase in use of inotropes over time.
251 Family Caregiver Strain and Likelihood of Heart Failure Patient Clinical Events: A Replication Study Julie T. Bidwell1, Christopher S. Lee2, Melinda K. Higgins1, Carolyn M. Reilly1, Patricia C. Clark3, Sandra B. Dunbar1; 1Emory University, Atlanta, GA; 2Boston College, Chestnut Hill, MA; 3Georgia State University, Atlanta, GA Introduction: Higher caregiver strain was identified as a predictor of lower patient clinical event-risk in a previous analysis of Italian heart failure (HF) patient-caregiver dyads. The purpose of this analysis was to determine whether this trade-off in patient and caregiver outcomes was culturally bound, or replicable in a North American sample. Hypothesis: We hypothesized that, similar to the Italian study, higher strain in North American caregivers would predict lower patient event-risk. Methods: This was a secondary analysis of data from a 3-arm (usual care, patient-family education, and family partnership intervention) randomized controlled trial to improve HF self-care. Data collection occurred pre-intervention and 4 and 8 months postintervention. Caregiver strain was measured pre-intervention using the 15-item Bakas Caregiving Outcomes Survey (BCOS: range 15-105, higher scores indicate more positive outcomes related to caregiving), and tertiles were used to divide caregivers into low, moderate, or high strain for analysis. Generalized linear regression was used to examine caregiver strain as a predictor of the likelihood of having any event (HF hospitalization, HF emergency room visit, or all-cause mortality) over time, controlling for intervention group and recent HF hospitalization (previous 4 months). Results: All patients (n=92) were NYHA Class II or III, with the majority being Class II (n=68, 73.9%). Patients and caregivers were in their mid-fifties on average (56.3§10.1 and 53.4§12.4 years, respectively) and racially diverse (n=58, 63.0% and n=59, 64.8% African American, respectively), with most patients being male (n=57, 62.0%) and most caregivers being female (n=75, 84.2%). The most common dyad type was spousal (n=40, 44.0%). Over the 8 months, 28 patients were hospitalized, 6 had an emergency room visit and 6 died. The average BCOS scores for the low, moderate, and high strain groups were 82.9§12.5 (range 66-105), 61.1§1.6 (range 60-65), and 52.1§7.4 (range 31-59), respectively. There was no difference in events by intervention group. High caregiver strain (as compared to low strain) was associated with 91.9% lower likelihood of the patient having an event over 8 months follow-up (OR=0.081, 95%CI=0.008-0.850, p=0.036). There was no significant difference in event-risk by moderate caregiver strain. Conclusions: Similar to previous findings in an Italian cohort, higher caregiver strain predicted lower HF patient clinical event-risk in this North American sample. Patient event-risk reductions may come with a cost for the family caregiver - a cost that has known sequelae (morbidity, mortality) and must be assessed and addressed.
252 Evaluation of Diuretics in Admitted Heart Failure Patients with Modification of Medication Order Entry Yekaterina Opsha, Rebeca Kane; Saint Barnabas Medical Center, Livingston, NJ Figure 1.