Palliative Care in HF Linked to Fewer Readmissions

Palliative care consultation during a heart failure hospitalization was followed by mixed results on healthcare utilization, according to a study of U.S. veterans.

Palliative care consultation was associated with a reduced incidence of multiple readmissions (adjusted HR 0.73, 95% CI 0.64-0.84) and less use of mechanical ventilation (adjusted HR 0.76, 95% CI 0.67-0.87) in the 6 months following the index hospital admission.

However, there was no reduction in pacemaker placement, cardiac surgery, or hemodialysis in the 6 months post-discharge.

Hospice care use was actually significantly higher in the palliative care cohort (34.8% vs 18.3%, P<0.001) on unadjusted analysis, James Rudolph, MD, SM, of Providence VA Medical Center in Rhode Island, and colleagues reported in the Journal of the American Heart Association.

“When allowed, palliative care may be used concurrently with curative, life-preserving treatment,” the authors said.

“Importantly, palliative care is not universally available. In this study, we found a wide variability in the palliative care encounters for patients hospitalized with HF among medical centers,” they reported.

The retrospective study was based on 58,712 HF patients admitted in 2010-2015 who had been randomly selected for the Veterans Administration External Peer Review Program. The primary analysis compared the 1,431 recipients of at least one hospital medical encounter with a palliative care professional matched by propensity score to peers who had no such consultations.

“With similar mortality between the groups, the stark difference in hospice enrollment between the palliative and matched cohorts demonstrates that the palliative approach may increase hospice referral and suggests that there is an HF population with an unmet need who may benefit from the additional layers of support that concurrent palliative care offers,” Rudolph’s team concluded.

“We postulate that palliative care is underutilized in part because of the misconception that it is synonymous with hospice. While both hospice and palliative care focus on symptom control, hospice enrolls patients who meet reimbursement eligibility criteria (a life expectancy of <6 months) and cannot be provided concurrently with curative treatment for the terminal condition,” the investigators said.

Veterans receiving hospice care at baseline were excluded from the analysis.

Compared with the overall cohort, the palliative group was older with more comorbidity, lower ejection fraction, more days in the hospital, more costs, and higher post-hospitalization mortality rates.

After matching, palliative care and control groups had similar characteristics, with average age over 75 years and more than 90% men.

Unmeasured confounding was a potential limitation of the observational study. There was also no external validation of the results derived from predominantly male veterans, Rudolph and colleagues acknowledged.

Palliative care is recommended by guidelines but remains underutilized among HF patients and those with cardiovascular disease in general.

“As HF progression is characterized by progressive functional decline, there is a growing understanding that concurrent palliative care can play an important role in attenuating the impact of HF, controlling symptoms, and providing continuity of care to meet the patients’ goals,” the researchers said.