Palliative Care Is Underutilized for Patients With Heart Failure

By 2030, heart failure (HF)—which tops the list of reasons for hospitalization among individuals older than 65 years—could tax the healthcare system $69.8 billion each year. Study results show the success of palliative care (PC) at reducing both healthcare costs and hospitalization. However, PC remains underutilized in patients with HF compared with those with cancer.

“Because many traditional interventions for HF, such as diuresis and inotropy, often improve symptoms, practitioners managing patients with HF, may not think that PC consultation is necessary,” wrote the authors of a study comparing the use of PC between patients with cancer and patients with HF. Their results appeared in a recent issue of JAMA Network Open.

The investigation focused on the changes PC was shown to bring about in patients with HF versus patients with cancer, in symptom improvement, care planning, and initiation of PC. The patient population came from community and academic hospitals from the Palliative Care Quality Network. Demographic characteristics included age, sex, primary diagnosis, and functional status via the Palliative Performance Scale (PPS; 100% being normal, 0% indicating death), which measures ambulation, activity level and evidence of disease, self-care, oral intake, and level of consciousness.

There were 16,741 patients with HF with a mean age of 75.3 years (95% CI, 75.0-75.5) and 40,531 patients with cancer whose mean age was 65.2 years (95% CI, 65.0-65.3). Their referrals for PC happened from January 1, 2013, through December 31, 2017, and data were analyzed from April 2018 through December 2019.

The patients with HF had lower mean PPS scores (35.6% [95% CI, 35.3%-35.9%] vs 42.4% [95% CI, 42.4%-42.6%]) and were more often in a critical care unit (35.3% vs 12.5%) at the time of their initial PC consultation compared with patients with cancer. Patients with HF also had longer mean hospital stays before their PC consultations: 4.6 (95% CI, 4.4-4.8) compared with 3.9 (95% CI, 3.8-4.0) days. And the rate of patients with cancer being referred to PC for symptoms other than pain was more than twice the rate for patients with HF: 21.7% versus 10.2%. Patients with HF had lower rates of moderate to severe pain, anxiety, and nausea (13.5%, 9.2%, and 2.0%, respectively) compared with patients with cancer (41.8%, 15.1%, and 9.1%).

Beyond PC, discharged patients with HF even had 50% lower referral rates to hospice care compared with patients with cancer (odds ratio, 0.50; 95% CI, 0.47-0.53; P <.001). Overall, patients with HF received less than half the referrals to PC that patients with cancer were given.

With symptom management so important in patients with HF, especially because of the high symptom burden, the authors attribute the discrepancy in referrals to PC to 2 issues:

1. A misunderstanding on the part of healthcare practitioners that PC is reserved solely for patients who are dying
2. Symptom improvement negates the need for even a PC consultation

“Routine symptom monitoring has been shown to improve survival for patients with metastatic cancer undergoing chemotherapy and may be of benefit in patients with HF. For now, cardiologists, primary care physicians, and hospitalists taking care of patients with HF should consider involving PC specialists early not only for care planning but also for assistance with symptom management,” they concluded.

An accompanying commentary proposed 3 solutions:

1. Integrate PC into routine care for patients with HF.
2. Involve the PC team early for candidates who are ineligible for heart transplants.
3. Educate on what PC is exactly and emphasize the difference between PC and hospice care.

Reference

Liu AY, Riordan DL, Marks AK, Bischoff KE, Pantilat SZ. A comparison of hospitalized patients with heart failure and cancer referred to palliative care. JAMA Network Open. 20205;3(2):e200020. doi: 10.1001/jamanetworkopen.2020.0020.