Variation in Specialist Palliative Care Reach and Associated Factors Among People With Advanced Heart Failure in the Department of Veterans Affairs

Shelli L Feder; Ling Han; Yan Zhan; Erica A Abel; Kathleen M Akgün; Terri Fried; Mary Ersek; Nancy S Redeker

doi:10.1016/j.jpainsymman.2024.03.022

Variation in Specialist Palliative Care Reach and Associated Factors Among People With Advanced Heart Failure in the Department of Veterans Affairs

J Pain Symptom Manage. 2024 Mar 30:S0885-3924(24)00677-8. doi: 10.1016/j.jpainsymman.2024.03.022. Online ahead of print.

Authors

Shelli L Feder¹, Ling Han², Yan Zhan³, Erica A Abel⁴, Kathleen M Akgün², Terri Fried⁵, Mary Ersek⁶, Nancy S Redeker⁷

Affiliations

¹ Yale School of Nursing(S.L.F., Y.Z.), Orange, Connecticut, USA; VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA. Electronic address: shelli.feder@yale.edu.
² VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA; Yale Program on Aging(L.H., K.M.A., T.F.), New Haven, Connecticut, USA.
³ Yale School of Nursing(S.L.F., Y.Z.), Orange, Connecticut, USA.
⁴ VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA.
⁵ VA Connecticut Healthcare System(S.L.F., L.H., E.A.A., K.M.A., T.F.), West Haven, Connecticut, USA; Yale Program on Aging(L.H., K.M.A., T.F.), New Haven, Connecticut, USA; Yale School of Medicine(T.F.), Department of Internal Medicine, New Haven, CT, USA.
⁶ Veteran Experience Center(M.E.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennysylvania, USA; Leonard Davis Institute(M.E.), University of Pennsylvania, Philadelphia, Pennysylvania, USA.
⁷ University of Connecticut School of Nursing(N.S.R.), Storrs, Connecticut, USA.

PMID: 38561132
DOI: 10.1016/j.jpainsymman.2024.03.022

Abstract

Context: Clinical practice guidelines recommend palliative care for people with advanced heart failure (aHF), yet it remains underutilized.

Objectives: We examined medical center variation in specialist palliative care (SPC) and identified factors associated with variation among people with aHF.

Methods: We conducted a retrospective cohort study of 21,654 people with aHF who received healthcare in 83 Veterans Affairs Medical Centers (VAMCs) from 2018-2020. We defined aHF with ICD-9/10 codes and hospitalizations. We used random intercept multilevel logistic regression to derive SPC reach (i.e., predicted probability) for each VAMC adjusting for demographic and clinical characteristics. We then examined VAMC-level SPC delivery characteristics associated with predicted SPC reach including the availability of outpatient SPC (proportion of outpatient consultations), cardiology involvement (number of outpatient cardiology-initiated referrals), and earlier SPC (days from aHF identification to consultation).

Results: Of the sample the mean age = 72.9+/-10.9 years, 97.9% were male, 61.6% were White, and 32.2% were Black. The predicted SPC reach varied substantially across VAMCs from 9% to 57% (mean: 28% [95% Confidence Interval: 25%-30%]). Only the availability of outpatient SPC was independently associated with higher SPC reach. VAMCs, in which outpatient delivery made up the greatest share of SPC consultations (9% or higher) had 11% higher rates of SPC reach relative to VAMCs with a lower proportion of outpatient SPC.

Conclusion: SPC reach varies widely across VAMCs for people with aHF. Outpatient palliative is common among high-reach VAMCs but its role in reach warrants further investigation. Strategies used by high-reach VAMCs may be potential targets to test for implementation and dissemination.

Keywords: Heart failure; Hospice; Palliative care; Patterns; Variation.