Evaluating the Implementation of Specialist Palliative Care for Patients with Advanced Heart Failure

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Project Summary Over 280,000 people die from advanced heart failure each year in the United States. This population experiences burdensome symptoms, frequent hospitalizations, and delayed transitions to hospice care. Clinical practice guidelines recommend the use of palliative care for persons with advanced heart failure to address this population's many palliative care needs. However, nationally the uptake of specialist palliative care remains low, and implementation across hospitals varies widely, limiting effectiveness. As hospitals move to implement specialist palliative care into clinical practice for persons with advanced heart failure, there is little evidence to guide them as to what components are necessary or how to implement this care. Without such information, the uptake of specialist palliative care will remain low thereby contributing to poor care at the end of life. Our proposed project will address these critical knowledge gaps. Our long-term goal is to increase the low uptake of specialist palliative care and to improve end-of-life care quality among people with advanced heart failure. As a step towards this goal, the objective of this proposal is to identify modifiable factors and implementation strategies that medical centers can use to develop specialist palliative care programs for this population, beginning in the Department of Veterans Affairs (VA). The VA is the largest healthcare system in the United States and is the only healthcare system whose integrated electronic health record supports a rigorous and comprehensive evaluation of specialist palliative care delivery involving features of both palliative and cardiology practices. To accomplish our objectives, we will use a multisite, sequential, explanatory mixed methods design and a positive deviance approach. We will evaluate associations between specialist palliative care and cardiology program composition (i.e., structures) and operational characteristics (i.e., processes) and the uptake of specialist palliative care (Aim 1) and important outcomes of end-of-life care quality including hospice enrollment before the last seven days of life, and family-reported end-of-life care quality (Aim 2). We will accomplish these aims using a novel dataset comprised of patient and hospital-level data from 83 VA medical centers, detailed data on structures and processes of specialist palliative care and cardiology programs, and surveys of bereaved family members combined with Medicare and Medicaid claims. Next, we will compare structures, processes, and implementation strategies across twelve medical centers by conducting interviews with specialist palliative care and cardiology clinicians, and through the analysis of policy documents and consultation templates (Aim 3). We will integrate quantitative and qualitative data (Aim 4) to identify strategies that facilitate the effective delivery and implementation of specialist palliative care for persons with advanced heart failure. This proposal directly aligns with NOT-HL-20-737 by identifying real-world, pragmatic strategies that address barriers and facilitate sustained delivery of specialist palliative care. Findings from our project can inform and refine specialist palliative care programs nationwide for persons with advanced heart failure.