DeGroot Lyndsay, Pavlovic Noelle, Perrin Nancy, Gilotra Nisha A, Miller Hailey, Denfeld Quin E, McIlvennan Colleen K, Dy Sydney M, Davidson Patricia M, Szanton Sarah L, Abshire Saylor Martha
J Cardiovasc Nurs. 2024 Apr 17. doi: 10.1097/JCN.0000000000001087.
People with heart failure, particularly those who are physically frail, experience complex needs that can be addressed by palliative care (PC). However, we have a limited understanding of how the intersection of unmet PC needs and physical frailty contributes to health-related quality of life (HRQOL) and risk for hospitalization or mortality.
In this study, we sought to examine the association of unmet PC needs and physical frailty with clinical outcomes (baseline HRQOL and hospitalizations or mortality at 6 months).
We recruited a convenience sample of community-dwelling persons with heart failure from an urban hospital system who were older than 50 years and hospitalized in the last year. We measured physical frailty using the FRAIL scale (nonfrail, 0-2; frail, 3-5), PC needs using the Integrated Palliative Outcome Scale (range, 0-58; higher scores indicating higher needs), and HRQOL using the Kansas City Cardiomyopathy Questionnaire (range, 0-100; higher scores indicate higher HRQOL). We performed multivariable linear regression to test the relationships between physical frailty, PC needs, and HRQOL, and multivariable logistic regression for associations with all-cause 6-month hospitalization or mortality. We also performed an exploratory analysis of 4 PC needs/frailty groups (high PC needs/frail, high PC needs/nonfrail, low PC needs/frail, low PC needs/nonfrail) with outcomes.
In our overall sample (n = 298), mean (SD) age was 68 (9.8) years, 37% were women (n = 108), 28% identified as Black/African American (n = 84), and 65% had heart failure with preserved ejection fraction (n = 194). Mean PC needs score was 19.7, and frail participants (n = 130, 44%) had a significantly higher mean PC needs score than nonfrail participants (P < .001). Those with higher PC needs (Integrated Palliative Care Outcome Scale ≥ 20) had significantly worse HRQOL (P < .001) and increased odds of hospitalization or mortality (odds ratio, 2.5; P < .01) compared with those with lower PC needs, adjusting for covariates. Physically frail participants had significantly worse HRQOL (P < .001) and higher odds of hospitalization or mortality at 6 months (odds ratio, 2.6; P < .01) than nonfrail participants, adjusting for covariates. In an exploratory analysis, physically frail participants with high PC needs had the lowest HRQOL score, with an average score of 28.6 points lower (P < .001) and 4.6 times higher odds of hospitalization or mortality (95% confidence interval, 2.03-10.43; P < .001) than low-needs/nonfrail participants.
Higher unmet PC needs and physical frailty, separately and in combination, were associated with lower HRQOL and higher odds of hospitalization or mortality. Self-reported PC needs and physical frailty assessment in clinical settings may improve identification of patients at the highest risk for poor HRQOL and hospitalization or mortality amenable to PC intervention.
心力衰竭患者，尤其是身体虚弱者，有着复杂的需求，而姑息治疗（PC）可以满足这些需求。然而，我们对未满足的PC需求与身体虚弱的交集如何影响健康相关生活质量（HRQOL）以及住院或死亡风险了解有限。
在本研究中，我们试图探讨未满足的PC需求和身体虚弱与临床结局（基线HRQOL以及6个月时的住院或死亡率）之间的关联。
我们从一个城市医院系统中招募了一个便利样本，这些社区居住的心力衰竭患者年龄超过50岁且在过去一年中曾住院治疗。我们使用FRAIL量表（非虚弱，0 - 2分；虚弱，3 - 5分）测量身体虚弱程度，使用综合姑息治疗结局量表（范围，0 - 58分；分数越高表明需求越高）测量PC需求，使用堪萨斯城心肌病问卷（范围，0 - 100分；分数越高表明HRQOL越高）测量HRQOL。我们进行多变量线性回归以检验身体虚弱、PC需求和HRQOL之间的关系，并进行多变量逻辑回归以分析与6个月全因住院或死亡率的关联。我们还对4个PC需求/虚弱组（高PC需求/虚弱、高PC需求/非虚弱、低PC需求/虚弱、低PC需求/非虚弱）与结局进行了探索性分析。
在我们的总体样本（n = 298）中，平均（标准差）年龄为68（9.8）岁，37%为女性（n = 108），28%为黑人/非裔美国人（n = 84），65%的患者射血分数保留的心力衰竭（n = 194）。PC需求平均得分为19.7分，虚弱参与者（n = 130，44%）的PC需求平均得分显著高于非虚弱参与者（P <.001）。与PC需求较低者相比，调整协变量后，PC需求较高者（综合姑息治疗结局量表≥20）的HRQOL显著更差（P <.001），住院或死亡几率增加（优势比，2.5；P <.01）。身体虚弱的参与者与非虚弱参与者相比，调整协变量后，HRQOL显著更差（P <.001），6个月时住院或死亡几率更高（优势比，2.6；P <.01）。在探索性分析中，PC需求高的身体虚弱参与者的HRQOL得分最低，平均得分比低需求/非虚弱参与者低28.6分（P <.001），住院或死亡几率高4.6倍（95%置信区间，2.03 - 10.43；P <.001）。
未满足的PC需求较高和身体虚弱，单独或共同存在，均与较低的HRQOL以及较高的住院或死亡几率相关联。在临床环境中进行自我报告的PC需求和身体虚弱评估，可能会改善对HRQOL差以及适合PC干预的住院或死亡风险最高的患者的识别。
