Department of Medicine, University of California, San Francisco.
Division of Palliative Medicine, University of California, San Francisco.
JAMA Netw Open. 2020 Feb 5;3(2):e200020. doi: 10.1001/jamanetworkopen.2020.0020.
Growing evidence shows that palliative care (PC) improves treatment outcomes in patients with heart failure (HF), but few large-scale studies have prospectively evaluated the processes and outcomes associated with PC consultation for such patients in the real world.
To characterize processes and outcomes of PC consultations for hospitalized patients with HF compared with patients with cancer.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study of inpatient encounters at community and academic hospitals in the Palliative Care Quality Network enrolled participants between 2013 and 2017. Of a total of 135 197 patients, 57 272 adults with a primary diagnosis of HF or cancer receiving PC consultation were enrolled. Data analysis was performed from April 2018 to December 2019.
Primary diagnosis of HF or cancer.
Symptom improvement and changes in care planning documentation after PC consultation.
At the time of consultation, patients with HF were older (mean age, 75.3 years [95% CI, 75.0-75.5 years] vs 65.2 years [95% CI, 65.0-65.3 years]; P < .001), had lower Palliative Performance Scale scores (mean, 35.6% [95% CI, 35.3%-35.9%] vs 42.4% [95% CI, 42.2%-42.6%]; P < .001), and were more likely to be in a critical care unit (5808 of 16 741 patients [35.3%] vs 4985 of 40 531 patients [12.5%]; P < .001) or a telemetry or step-down unit (5802 of 16 741 patients [35.2%] vs 7651 of 40 531 patients [19.2%]; P < .001) compared with patients with cancer. Patients with HF were less likely than patients with cancer to be referred to PC within 24 hours of admission (6773 of 16 741 patients [41.2%] vs 19 348 of 40 531 patients [49.0%]; P < .001) and had longer hospitalizations before receiving PC consultation requests (mean, 4.6 days [95% CI, 4.4-4.8 days] vs 3.9 days [95% CI, 3.8-4.0 days]; P < .001). Patients with HF were referred less frequently for symptoms other than pain (1686 of 16 488 patients [10.2%] vs 8587 of 39 609 patients [21.7%]; P < .001), but were equally likely to report improvements in anxiety (odds ratio, 0.85; 95% CI, 0.71-1.02; P = .08) and more likely to report improvements in dyspnea (odds ratio, 2.17; 95% CI, 1.83-2.57; P < .001) compared with patients with cancer. Patients with HF were less likely than those with cancer to be discharged alive (odds ratio, 0.78; 95% CI, 0.64-0.96; P = .02) or to be referred to hospice (odds ratio, 0.50; 95% CI, 0.47-0.53; P < .001).
These findings suggest that PC referral comes late for patients with HF and is used primarily to discuss care planning. Practitioners caring for patients with HF should consider involving PC experts earlier for symptom management.
越来越多的证据表明，姑息治疗（PC）可改善心力衰竭（HF）患者的治疗结局，但很少有大规模研究前瞻性评估此类患者在真实世界中接受 PC 咨询的相关过程和结局。
比较 HF 住院患者与癌症患者的 PC 咨询过程和结局。
设计、地点和参与者：这项在姑息治疗质量网络的社区和学术医院进行的住院患者队列研究于 2013 年至 2017 年期间纳入了参与者。在总共 135197 名患者中，有 57272 名患有 HF 或癌症的成年患者接受了 PC 咨询，他们被纳入本研究。数据分析于 2018 年 4 月至 2019 年 12 月进行。
HF 或癌症的主要诊断。
PC 咨询后症状改善和护理计划文档的变化。
在咨询时，HF 患者年龄较大（平均年龄，75.3 岁[95%CI，75.0-75.5 岁] vs 65.2 岁[95%CI，65.0-65.3 岁]；P<0.001），姑息治疗表现量表评分较低（平均，35.6%[95%CI，35.3%-35.9%] vs 42.4%[95%CI，42.2%-42.6%]；P<0.001），更可能在重症监护病房（5808 名/16741 名患者[35.3%] vs 4985 名/40531 名患者[12.5%]；P<0.001）或心电监护或下调病房（5802 名/16741 名患者[35.2%] vs 7651 名/40531 名患者[19.2%]；P<0.001）中。与癌症患者相比，HF 患者在入院后 24 小时内被转介到 PC 的可能性更小（6773 名/16741 名患者[41.2%] vs 19348 名/40531 名患者[49.0%]；P<0.001），并且在接受 PC 咨询请求之前的住院时间更长（平均，4.6 天[95%CI，4.4-4.8 天] vs 3.9 天[95%CI，3.8-4.0 天]；P<0.001）。HF 患者除疼痛外，其他症状的转介频率较低（1686 名/16488 名患者[10.2%] vs 8587 名/39609 名患者[21.7%]；P<0.001），但报告焦虑改善的可能性相同（比值比，0.85；95%CI，0.71-1.02；P=0.08），呼吸困难改善的可能性更高（比值比，2.17；95%CI，1.83-2.57；P<0.001）。与癌症患者相比，HF 患者更不可能活着出院（比值比，0.78；95%CI，0.64-0.96；P=0.02）或被转介到临终关怀（比值比，0.50；95%CI，0.47-0.53；P<0.001）。
这些发现表明，HF 患者的 PC 转介较晚，主要用于讨论护理计划。为 HF 患者提供治疗的医务人员应考虑更早地让姑息治疗专家介入进行症状管理。
