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Caregivers’ Perceptions of Illness Severity in Advanced Heart Failure
The 19th Annual Scientific Meeting
Figure 1.
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to manage rural patients with chronic and complex medical conditions, through an innovative model of knowledge sharing via tele-health technology. Through SCAN-ECHO, rural Oregon primary care providers (PCPs) have access to specialty consultations at Veterans Affairs (VA) Portland Health Care System. The objective of this project was to remotely perform therapeutic management consultations by heart failure specialists in order to optimize timely and appropriate rural HF patient care. Methods: A collaborative therapy review (CTR) team consisting of a cardiologist, HF-trained PA, and a HF-trained pharmacist was assembled and electronic chart audits were performed on patients with an ICD-9 code for HF in the panels of 12 VA PCPs who volunteered, in a rural Oregon catchment area . Patients who were deceased or with an EFO40% were excluded. Patient vitals, laboratory values, medications, comorbidity, device, and medical history data were reviewed to identify opportunities for guideline-directed improvement in care. Specific medication, laboratory, and/or device recommendations were sent to PCPs via a brief note in the electronic medical record. When applicable, pre-prepared electronic orders were also included. The frequency of PCP acceptance of CTR recommendations was calculated overall and stratified by recommendation class. Results: A total of 455 patients were identified. To date, 312 HF patients have been reviewed; 12 (4.2%) were excluded because they were deceased and 160 (51.3%) because their EF was O40%. Of the remaining patients, opportunities for improvements in care were identified for 82 individuals (58.6%). The majority of patients were male (97.6%) and Caucasian (97.6%). A total of 185 therapeutic recommendations were made with each patient receiving an average of 2.18 recommendations. Most recommendations centered on changes in medication therapy (66.3%), followed by updated labs (32.1%), and device recommendations (1.6%). Overall, 149 (80.5%) of recommendations were accepted by PCPs. Acceptance rates were similar across recommendation types with 79.5% of medication, 83.3% of lab, and 66.7% of device recommendations being accepted (p50.53). Among medication recommendations, most centered on increasing doses or initiating beta-blocker therapy (28.7%); increasing/decreasing doses or initiating ACE-Inhibitors (12.3%); and initiating statin therapy (11.5%). Conclusion: HF specialists aimed at identifying opportunities to optimize HF therapy can help enhance the effectiveness of PCP-managed HF care in rural communities. Efforts are under way to expand to other rural communities.
Caregivers’ Perceptions of Illness Severity in Advanced Heart Failure Judith E. Hupcey, Lisa A. Kitko; The Pennsylvania State University, University Park, PA Aims: Heart failure impacts over 5 million Americans, with this number doubling by 2030. The future global impact of heart failure has been called an “emerging pandemic”. Further complicating the high incidence of HF, is a five-year mortality rate that approaches 50% and an unpredictable heart failure trajectory. End-of-life (EOL) treatments for HF, including EOL discussions and referral to appropriate services, such as palliative care and hospice, have been recommended to meet the needs of heart failure patients and their family caregivers, but are not widely used by this population. To help determine why EOL services may not be utilized, when offered, this study investigated the perceptions of illness severity in family caregivers of patients with advanced heart failure. Methods: As part of a longitudinal study investigating the EOL trajectory of patients with heart failure and their caregivers, 63 adult family caregivers of heart failure patients with a predicted survival of !1-year (n526) versus !2-year (n537) were interviewed. During the initial interview, caregivers were asked to describe their understanding of the patient’s illness progression and where they envisioned the patient in one year. Qualitative content analysis of the interviews was done individually followed by a research team group comparative analysis. Results: The majority of caregivers (75%) did not understand the severity of the patient’s heart failure. There were no differences between the predicted survival of !1 year and !2 year groups in the caregivers’ perceptions of the patients’ illness severity. There were no significant differences in gender, age, or caregiver relationship between caregivers who did and those who did not perceive the severity of the patient’s illness. A small percentage of the caregivers focused on illness severity but attributed the life-limiting nature to another chronic disease process such as diabetes or advanced renal failure. Out of the 29 patients who have died during study enrollment, only 8 of the caregivers perceived HF as a terminal disease. The main theme identified in the caregivers who did not perceive the severity of the illness was hopefulness for the patient’s return to baseline or improvement of symptoms. For those caregivers who did perceive the severity of the patient’s illness, the main theme identified was uncertainty regarding the patient’s future. Conclusions: The majority of caregivers did not view the patient’s heart failure as a terminal disease even with a limited predicted survival. Lack of perception of the severity of advanced heart failure may impact caregivers’ acceptance of EOL discussions, EOL planning and EOL services.
126 Remote Specialty Therapeutic Management Enhances Patient-Centered Heart Failure Care in a Rural Community Setting Harleen Singh1, Jessina C. McGregor1, Cindy L. Quale2, Kelsie W. Flynn1, Samaneh Zhian1, Matt Atkinson1, Kayla E. Ruhl1, Kate H. Unterberger1, Greg C. Larsen2; 1 OSU/OHSU College of Pharmacy, Portland, OR; 2Portland Veterans Affairs Health Care System, Portland, OR Background: Rural Veterans have increased barriers to accessing healthcare services, particularly specialty care. The Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) project was implemented
127 A Markov Model-based Monte Carlo Simulation to Assess Variation in Financial Burden and Health Outcomes for Cardiac Implantable Electronic Devices Based on Device and Patient Characteristics Juergen A. Klenk1, Arnold J. Greenspon2, Edmund C. Lau3, Jasmine Patel4, Jordana K. Schmier1, Pamela M. McMahon5; 1Exponent, Inc., Alexandria, VA; 2Thomas Jefferson University, Philadelphia, PA; 3Exponent, Inc., Menlo Park, CA; 4 Exponent, Inc., Philadelphia, PA; 5Exponent, Inc., Natick, MA Introduction: The effects of device and patient characteristics on health and economic outcomes in patients with Cardiac Implantable Electronic Devices (CIEDs) are unclear. Claims data and modeling can be used to evaluate healthcare costs and outcomes for patients with CIEDs under a variety of scenarios that vary by battery longevity, patient co-morbidity profile, and inpatient/outpatient ratio. Hypothesis: Increases in CIED battery longevity will result in clinically meaningful reductions in infections and complications and reduced healthcare costs, across a variety of scenarios. Methods: We developed a Markov model and used Monte Carlo simulation to follow patients through primary implant, post-procedure maintenance, generator replacement, and full revision states. Patients were simulated in 3-month increments for a total of 15 years or until death. Key variables included Charlson comorbidity index, CIED type (ICD or CRT-D), battery longevity, mortality rates (procedure and all-cause), infection and non-infectious complication rates, and inpatient/ outpatient settings. Cost elements included facility and professional costs for all procedures, maintenance, and for infections and non-infectious complications. All data (probabilities, distributions) were based on Medicare data from 2004-2013 using the 5% sample. Outcomes included discounted (at 3%) costs and life years, numbers of battery replacements and full revisions, and numbers of infections and non-infectious complications. Results: A two-year increase in battery longevity in ICDs yielded a reduction in total costs per patient (by 7%), and reduced numbers of revisions (by 20%), battery changes (by 41%), and infections (by 11%), but did not decrease non-infectious complications. The analogous reductions for CRT-Ds were 10% (costs), 23% (revisions), 47% (battery changes), 31% (infections), and 11% (complications). The two-year increase battery longevity was associated with a higher percentage of patients (15% for ICD, 22% for CRT-D) undergoing no repeat procedures by the end of the simulation. Similar trends were observed when patient comorbidity profiles or inpatient/outpatient ratios were varied. Conclusions: Based on modeling results, as battery longevity increases, patients experience fewer adverse outcomes, and healthcare costs are reduced.
128 Increased risk of Cerebrovascular Death in Patients with ChemotherapyInduced Cardiomyopathy Emile Mehanna, Sadeer G. Al-Kindi, Mobolaji Ige, Sachin Kumar, Mohammad Kattea, Chantal ElAmm, Salil Deo, Rodolfo D. Benatti, Mahazarin Ginwalla, Soon J. Park, Guilherme H. Oliveira; Advanced Heart Failure & Transplant Center,
Figure 1.
125
HFSA
S61
to manage rural patients with chronic and complex medical conditions, through an innovative model of knowledge sharing via tele-health technology. Through SCAN-ECHO, rural Oregon primary care providers (PCPs) have access to specialty consultations at Veterans Affairs (VA) Portland Health Care System. The objective of this project was to remotely perform therapeutic management consultations by heart failure specialists in order to optimize timely and appropriate rural HF patient care. Methods: A collaborative therapy review (CTR) team consisting of a cardiologist, HF-trained PA, and a HF-trained pharmacist was assembled and electronic chart audits were performed on patients with an ICD-9 code for HF in the panels of 12 VA PCPs who volunteered, in a rural Oregon catchment area . Patients who were deceased or with an EFO40% were excluded. Patient vitals, laboratory values, medications, comorbidity, device, and medical history data were reviewed to identify opportunities for guideline-directed improvement in care. Specific medication, laboratory, and/or device recommendations were sent to PCPs via a brief note in the electronic medical record. When applicable, pre-prepared electronic orders were also included. The frequency of PCP acceptance of CTR recommendations was calculated overall and stratified by recommendation class. Results: A total of 455 patients were identified. To date, 312 HF patients have been reviewed; 12 (4.2%) were excluded because they were deceased and 160 (51.3%) because their EF was O40%. Of the remaining patients, opportunities for improvements in care were identified for 82 individuals (58.6%). The majority of patients were male (97.6%) and Caucasian (97.6%). A total of 185 therapeutic recommendations were made with each patient receiving an average of 2.18 recommendations. Most recommendations centered on changes in medication therapy (66.3%), followed by updated labs (32.1%), and device recommendations (1.6%). Overall, 149 (80.5%) of recommendations were accepted by PCPs. Acceptance rates were similar across recommendation types with 79.5% of medication, 83.3% of lab, and 66.7% of device recommendations being accepted (p50.53). Among medication recommendations, most centered on increasing doses or initiating beta-blocker therapy (28.7%); increasing/decreasing doses or initiating ACE-Inhibitors (12.3%); and initiating statin therapy (11.5%). Conclusion: HF specialists aimed at identifying opportunities to optimize HF therapy can help enhance the effectiveness of PCP-managed HF care in rural communities. Efforts are under way to expand to other rural communities.
Caregivers’ Perceptions of Illness Severity in Advanced Heart Failure Judith E. Hupcey, Lisa A. Kitko; The Pennsylvania State University, University Park, PA Aims: Heart failure impacts over 5 million Americans, with this number doubling by 2030. The future global impact of heart failure has been called an “emerging pandemic”. Further complicating the high incidence of HF, is a five-year mortality rate that approaches 50% and an unpredictable heart failure trajectory. End-of-life (EOL) treatments for HF, including EOL discussions and referral to appropriate services, such as palliative care and hospice, have been recommended to meet the needs of heart failure patients and their family caregivers, but are not widely used by this population. To help determine why EOL services may not be utilized, when offered, this study investigated the perceptions of illness severity in family caregivers of patients with advanced heart failure. Methods: As part of a longitudinal study investigating the EOL trajectory of patients with heart failure and their caregivers, 63 adult family caregivers of heart failure patients with a predicted survival of !1-year (n526) versus !2-year (n537) were interviewed. During the initial interview, caregivers were asked to describe their understanding of the patient’s illness progression and where they envisioned the patient in one year. Qualitative content analysis of the interviews was done individually followed by a research team group comparative analysis. Results: The majority of caregivers (75%) did not understand the severity of the patient’s heart failure. There were no differences between the predicted survival of !1 year and !2 year groups in the caregivers’ perceptions of the patients’ illness severity. There were no significant differences in gender, age, or caregiver relationship between caregivers who did and those who did not perceive the severity of the patient’s illness. A small percentage of the caregivers focused on illness severity but attributed the life-limiting nature to another chronic disease process such as diabetes or advanced renal failure. Out of the 29 patients who have died during study enrollment, only 8 of the caregivers perceived HF as a terminal disease. The main theme identified in the caregivers who did not perceive the severity of the illness was hopefulness for the patient’s return to baseline or improvement of symptoms. For those caregivers who did perceive the severity of the patient’s illness, the main theme identified was uncertainty regarding the patient’s future. Conclusions: The majority of caregivers did not view the patient’s heart failure as a terminal disease even with a limited predicted survival. Lack of perception of the severity of advanced heart failure may impact caregivers’ acceptance of EOL discussions, EOL planning and EOL services.
126 Remote Specialty Therapeutic Management Enhances Patient-Centered Heart Failure Care in a Rural Community Setting Harleen Singh1, Jessina C. McGregor1, Cindy L. Quale2, Kelsie W. Flynn1, Samaneh Zhian1, Matt Atkinson1, Kayla E. Ruhl1, Kate H. Unterberger1, Greg C. Larsen2; 1 OSU/OHSU College of Pharmacy, Portland, OR; 2Portland Veterans Affairs Health Care System, Portland, OR Background: Rural Veterans have increased barriers to accessing healthcare services, particularly specialty care. The Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) project was implemented
127 A Markov Model-based Monte Carlo Simulation to Assess Variation in Financial Burden and Health Outcomes for Cardiac Implantable Electronic Devices Based on Device and Patient Characteristics Juergen A. Klenk1, Arnold J. Greenspon2, Edmund C. Lau3, Jasmine Patel4, Jordana K. Schmier1, Pamela M. McMahon5; 1Exponent, Inc., Alexandria, VA; 2Thomas Jefferson University, Philadelphia, PA; 3Exponent, Inc., Menlo Park, CA; 4 Exponent, Inc., Philadelphia, PA; 5Exponent, Inc., Natick, MA Introduction: The effects of device and patient characteristics on health and economic outcomes in patients with Cardiac Implantable Electronic Devices (CIEDs) are unclear. Claims data and modeling can be used to evaluate healthcare costs and outcomes for patients with CIEDs under a variety of scenarios that vary by battery longevity, patient co-morbidity profile, and inpatient/outpatient ratio. Hypothesis: Increases in CIED battery longevity will result in clinically meaningful reductions in infections and complications and reduced healthcare costs, across a variety of scenarios. Methods: We developed a Markov model and used Monte Carlo simulation to follow patients through primary implant, post-procedure maintenance, generator replacement, and full revision states. Patients were simulated in 3-month increments for a total of 15 years or until death. Key variables included Charlson comorbidity index, CIED type (ICD or CRT-D), battery longevity, mortality rates (procedure and all-cause), infection and non-infectious complication rates, and inpatient/ outpatient settings. Cost elements included facility and professional costs for all procedures, maintenance, and for infections and non-infectious complications. All data (probabilities, distributions) were based on Medicare data from 2004-2013 using the 5% sample. Outcomes included discounted (at 3%) costs and life years, numbers of battery replacements and full revisions, and numbers of infections and non-infectious complications. Results: A two-year increase in battery longevity in ICDs yielded a reduction in total costs per patient (by 7%), and reduced numbers of revisions (by 20%), battery changes (by 41%), and infections (by 11%), but did not decrease non-infectious complications. The analogous reductions for CRT-Ds were 10% (costs), 23% (revisions), 47% (battery changes), 31% (infections), and 11% (complications). The two-year increase battery longevity was associated with a higher percentage of patients (15% for ICD, 22% for CRT-D) undergoing no repeat procedures by the end of the simulation. Similar trends were observed when patient comorbidity profiles or inpatient/outpatient ratios were varied. Conclusions: Based on modeling results, as battery longevity increases, patients experience fewer adverse outcomes, and healthcare costs are reduced.
128 Increased risk of Cerebrovascular Death in Patients with ChemotherapyInduced Cardiomyopathy Emile Mehanna, Sadeer G. Al-Kindi, Mobolaji Ige, Sachin Kumar, Mohammad Kattea, Chantal ElAmm, Salil Deo, Rodolfo D. Benatti, Mahazarin Ginwalla, Soon J. Park, Guilherme H. Oliveira; Advanced Heart Failure & Transplant Center,