Effects of a transitional palliative care model on patients with end-stage heart failure: a randomised controlled trial

Abstract

Objective To examine the effects of home-based transitional palliative care for patients with end-stage heart failure (ESHF) after hospital discharge. Methods This was a randomised controlled trial conducted in three hospitals in Hong Kong. The recruited subjects were patients with ESHF who had been discharged home from hospitals and referred for palliative service, and who met the specified inclusion criteria. The interventions consisted of weekly home visits/telephone calls in the first 4 weeks then monthly follow-up, provided by a nurse case manager supported by a multidisciplinary team. The primary outcome measures were any readmission and count of readmissions within 4 and 12 weeks after index discharge, compared using χ 2 tests and Poisson regression, respectively. Secondarily, change in symptoms over time between control and intervention groups were evaluated using generalised estimating equation analyses of data collected using the Edmonton Symptom Assessment Scale (ESAS). Results The intervention group (n=43) had a significantly lower readmission rate than the control group (n=41) at 12 weeks (intervention 33.6% vs control 61.0% χ 2 =6.8, p=0.009). The mean number (SE) of readmissions for the intervention and control groups was, respectively, 0.42 (0.10) and 1.10 (0.16) and the difference was significant (p=0.001). The relative risk (CI) for 12-week readmissions for the intervention group was 0.55 (0.35 to 0.88). There was no significant difference in readmissions between groups at 4 weeks. However, when compared with the control group, the intervention group experienced significantly higher clinical improvement in depression (45.9% vs 16.1%, p<0.05), dyspnoea (62.2% vs 29.0%, p<0.05) and total ESAS score (73.0% vs 41.4%, p<0.05) at 4 weeks. There were significant differences between groups in changes over time in quality of life (QOL) measured by McGill QOL (p<0.05) and chronic HF (p<0.01) questionnaires. Conclusions This study provides evidence of the effectiveness of a postdischarge transitional care palliative programme in reducing readmissions and improving symptom control among patients with ESHF. Trial registration number HKCTR-1562; Results.

Palliative Care Interventions for Patients with Heart Failure: A Systematic Review and Meta-Analysis

“…1). [30][31][32][33][34][35][36][37][38][39][40][41][42][43] A review of bibliographies identified one additional study. 44 The 15 studies included eight randomized controlled trials, two prospective nonrandomized controlled trials, and five retrospective controlled studies.…”

“…Patient quality of life significantly improved in 83% (5/6) of studies, 32,[39][40][41]43 and satisfaction significantly improved in 67% (2/3) of studies. 30,39,44 With respect to symptoms, improvement was the most frequently seen with dyspnea and sleep quality, 30,32,39,40,43 depression, 39,40,43 and anxiety. 30,32,40 The assessment(s) used to gather information about symptoms varied across studies.…”

“…Eight studies included only patients with HF. [36][37][38][39][40][41][42][43] Other studies included the following additional diagnoses: cancer, 30,[33][34][35]44 chronic obstructive lung disease, [30][31][32]44 cirrhosis, 27,35 neurologic disease, 35 and human immunodeficiency virus (HIV). 34 Study size ranged from 36 patients to 16,613 patients (mean = 2629; median 210).…”

“…Studies were performed in the following settings: outpatient (n = 2), 30,43 inpatient (n = 5), 31,34,35,38,40 home (n = 5), 32,39,41,42,44 hospice (n = 2), 33,36 and all settings (n = 1) 37 (Table 2).…”

“…The studies with improvement in the largest number of outcomes prioritized the integration of interdisciplinary HF and PC care. 39,41,42 The most common type of intervention utilized a core team of professionals from at least two disciplines with the support of other services as needed, but without emphasizing integrative PC and HF care. 30,32,37,38,40,44 Two interventions were conducted primarily by a physician or nurse.…”