Impacts of transitional palliative care for end-stage heart failure patients

Abstract

Background: Heart failure (HF) is a chronic, progressive life-threatening illness. Along the illness trajectory, in particular approaching to end-stage, patients with HF suffer from significant physical and psycho-social-spiritual symptom burden, which are associated with increased hospital admissions and impaired quality of life (QOL) on these patients. Given that HF poses tremendous burden on patients, healthcare system, and society, the impact of HF can be reduced if effective management is implemented. Post discharge care coordination is still an unmet need for many patients with end-stage HF (ESHF), particularly when they are returned home from hospital after an acute exacerbation. Additionally, patients with ESHF seldom receive specialist palliative care (PC), while PC is considered appropriate for them. It is essential to develop a transitional PC intervention, which is a Home-based Palliative Heart Failure (HPHF) program, and test its effectiveness in order to build research evidence and to guide clinical practice. Aim: The aim of this study was to test the effectiveness of a transitional PC intervention on health services utilization, QOL, symptom intensity, functional status, and satisfaction with care for patients with ESHF. Design: This study was a prospective, single-blinded, two-group randomized controlled trial. Eighty-four hospitalized patients suffered from ESHF and being referred to PC were recruited from three hospitals in Hong Kong. The participants were randomly allocated to either an intervention group (n = 43) or control group (n = 41). Both groups received the usual discharge planning in the study hospital. The intervention group received HPHF program delivered by PC-nurse case managers who were supported by a team including PC physicians, social workers, and volunteers. Structured home visits and telephone follow up were the care delivery strategies in the HPHF program, and all nursing actions were protocol-driven. Hospital readmission was the primary outcome, other outcomes included accident and emergency department (AED) attendance, hospital length of stay, QOL, symptom intensity, functional status, and patient satisfaction with care. The participants were assessed on the outcome variables at baseline (T1), at 4 weeks (T2) and at 12 weeks (T3) post hospital discharge. Results: The intervention group had a statistically significant lower readmission rate than the control group at 12 weeks post discharge (p = 0.009). There was no significant difference in hospital readmissions between the two groups at 4 weeks post discharge. The intervention group had a statistically significant lower AED attendance rate (p = 0.015) than the control group at 12 weeks. There was no significant difference in AED attendance rate between the two groups at 4 weeks. Within 12 weeks post discharge period, result showed a shorter length of hospital stay in the intervention group, but it was not significant (p = 0.08). Results of the repeated measures analysis of variance revealed a statistically significant between-group effect (p = 0.016), interaction group by time effect (p = 0.032), and within-group effect (p < 0.001) in the McGill QOL total score at 12 weeks post discharge. No significant between-group difference was found for the symptom intensity and functional status at 12 weeks. However, there were within-group differences detected, where the intervention group showed improvement in the symptom tiredness, feeling of well-being, and the total symptom score measured by Edmonton Symptom Assessment Scale. The intervention group had higher satisfaction with care than the control group at 12 weeks post discharge. Conclusion: This study has provided encouraging evidence that the HPHF program was effective in reducing hospital readmission, AED attendance, improving QOL, symptom intensity, and satisfaction with care in supporting patients with ESHF. The results of this study suggest that integrating PC into HF management using transitional care model was able to bring about positive effects to ESHF patients who experienced hospitalization due to HF exacerbation. This study informs health care providers and policy makers that transitional care support is beneficial to both patient and clinical outcomes.