ObjectiveTo identify factors influencing cardiologists’ and hospitalists’ decisions regarding palliative care referral among hospitalised patients with advanced heart failure.DesignAn exploratory, randomised vignette-based survey.SettingCardiology and hospitalist divisions at three Michigan State institutions and the Society of Hospital Medicine’s Michigan Chapter.Participants145 hospitalists and 64 cardiologists.Outcome measuresPrimary outcomes included participants’ reports of their likelihood of referring a standardised patient with an acute heart failure exacerbation with multiple prior hospital admissions and acute renal failure to palliative care (scale of 0%–100%) after the initial stem and after being cued with three randomised vignette modifiers, including the presence versus the absence of continuity with an outpatient cardiologist; the presence versus the absence of documented advance care planning; and the patient voicing that he is accepting of his severe illness versus wanting everything done. Adjusted generalised linear models and predictive margins were used to evaluate the impact of each randomised modifier on referral decisions. An interaction term evaluated the effect of provider specialty on outcomes. Secondary outcomes included participants’ reports of their general practices around palliative care delivery to hospitalised patients with heart failure.ResultsResponse rate was 31.3%. Predictive margins from generalised linear models demonstrated a statistically significantly higher likelihood of referral to inpatient palliative care if the patient lacked an outpatient cardiologist (mean difference: 6.3% (95% CI 1.8% to 10.8%)); had prior advance care planning documentation (mean difference: 9.7% (95% CI 4.4% to 15.0%)); and was accepting of illness severity (mean difference: 29.6% (95% CI 24.8% to 34.4%)). No interaction effect was noted based on provider specialty. Most hospitalists and cardiologists were unaware of palliative care guidelines for patients with heart failure (74.3% vs 70.3%, p=0.71).ConclusionsA number of patient and provider factors influence palliative care referral decisions in hospitalised patients with advanced heart failure.
Background
Heart failure is a common and devastating complication of type 2 diabetes (T2D). Prompt recognition of heart failure may avert hospitalization, facilitate use of guideline-directed therapies, and impact choice of T2D medications. We sought to determine the rate and factors associated with heart failure documentation in T2D patients with evidence of volume overload requiring loop diuretics.
Methods
DCR is an on-going, prospective US registry of outpatient T2D patients from > 5000 cardiology, endocrinology, and primary care clinicians (current analysis used data from 2013–2019). Among T2D patients receiving loop diuretics, we examined the rate of chart documentation of heart failure. We used a 3-level hierarchical logistic regression model (patients nested within physician within practice) to examine factors associated with heart failure diagnosis.
Results
Among 1,322,640 adults with T2D, 225,125 (17.0%) were receiving a loop diuretic, of whom 91,969 (40.9%) had documentation of heart failure. Male sex, lower body mass index, atrial fibrillation, chronic kidney disease, and coronary artery disease were associated with greater odds of heart failure diagnosis. After accounting for patient factors, patients seen by cardiologists were the most likely to have HF documented followed by PCPs and then endocrinologists.
Conclusions
Among US outpatients with T2D, 17% of patients had evidence of volume overload—defined by loop diuretic prescription—of whom fewer than half had a clinical diagnosis of heart failure. While there may be non-heart failure indications for loop diuretics, our data suggest that a substantial proportion of T2D patients may have unrecognized heart failure and therefore could be missing opportunities for targeted therapies that could alter the clinical course of heart failure.
Sixty-two former New Zealand timber workers who were exposed to pentachlorophenol (PCP) at work were interviewed, examined, and assessed both by laboratory investigations and psychometrically for clinical syndromes that could be related to PCP exposure. Three such syndromes were identified: an acute complex of fever, headaches, upper and lower respiratory tract and eye irritation, skin disease, and foul smelling and discolored sweat; a chronic fatigue syndrome, beginning while still at work and frequently persisting; and a delayed encephalopathy. Neither of the sustained syndromes was considered characteristic of PCP poisoning, and many confounders were identified. An exposure index and a test-of-poisoning score had a statistically insignificant correlation.
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