Home-Based Palliative Program Improves Clinical Outcomes in End-Stage Heart Failure Patients: Randomized Controlled Trial (RD)

Purpose: Heart failure (HF) is a complex clinical syndrome affecting approximately 6 million people in the United States. The prognosis of HF is difficult to predict, and HF is described as being as ‘malignant’ as many kinds of cancer. When HF progresses to the end-stage, the patients present with a wide range of distressing symptoms and poor quality of life. Importantly, studies have shown that the needs of end-stage HF patients were not met. The international guidelines highlighted the importance of introducing palliative care into HF management. Palliative care is a multidisciplinary, holistic approach that aims to improve quality of life and provide care in the relief of distressing symptoms for individuals facing life-limiting conditions. Since, many end-stage HF patients encounter HF exacerbations because the symptoms are refractory to medical therapy, requiring multiple hospital admissions. In addition, the inadequate symptom management leads to readmission to the hospital after discharge given an enormous burden to the health care system. Previous studies have demonstrated that transitional care is effective to reduce hospital readmission rate in HF population. However, the interventions targeted to the group suffered from end-stage HF seems lacking, in particular, interventions incorporating palliative care elements. It is, therefore, hypothesized that a Home-based Palliative Heart Failure (HPHF) program would improve clinical outcomes in patients with end-stage HF. The purpose of this study was to examine the effectiveness of a HPHF program coordinated by specialist palliative home care nurses to end-stage HF patients.

Methods: This was a two-group randomized controlled trial conducted in three hospitals in Hong Kong. End-stage HF patients were identified at hospitalization. The recruited subjects were patients with ESHF who had been discharged home and referred for specialist palliative service, and who met the specified inclusion criteria. The intervention was a 12-week HPHF program and the program development was based on the transitional care model and the palliative care elements. The HPHF program consisted of weekly home visits/telephone calls in the first 4 weeks then monthly follow-up. The HPHF program was provided by trained nurse case managers who had experiences in palliative home care, and they were supported by a multidisciplinary team. The nurse case managers performed comprehensive symptom assessment, management, and evaluation for the patients, coordinated health and social care in hospital and community, and collaborated with the patients, their family members, and the multidisciplinary team members. Evidence-based protocols were adopted throughout the intervention. Outcomes included hospital readmissions, days to first re-hospitalization, hospital days, and patient satisfaction with care were measured at 4 and 12 weeks post discharge. Data was collected from May 2013 to June 2015.

Results: A total of 84 eligible subjects were randomized. Mean age of the subjects was 78.3, 52.4% were male. The HPHF group (n=43) had a significantly lower readmission rate than the control group (n=41) at 12 weeks (HPHF 33.6% vs control 61.0% χ2 =6.8, p=0.009). Patients randomized to receive the HPHF program had a lower risk of readmission (relative risk, 0.55; 95% confidence interval, 0.35 to 0.88). There was no significant difference in readmissions between groups at 4 weeks. Time to first readmission was longer in the HPHF group (median: HPHF12 days vs control 9 days) (Z = -0.61, p = 0.55). Total days spent in the hospital while readmitted were fewer in the HPHF group (median: HPHF4 days vs control 8.5 days) (Z = -1.74, p = 0.08). Upon completion of the program, Patients received the HPHF program had higher satisfaction with care (p = 0.001).

Conclusion: This study adds to the evidence that an intensive 4-week transitional home-based program sustained by monthly follow-up is effective in reducing readmissions, increasing the length of time between hospital discharge and readmission, and improving satisfaction with care among ESHF patients on returning home after hospital discharge, thus demonstrating great promise for improving clinical outcomes. The design of the HPHF program in this study contained evidence-based elements identified by a current systematic review that were found to be effective in reducing hospital readmissions. In end-stage HF management, transit of the focus from curative treatment to symptom control in the continuum of care requires a multidisciplinary team support including cardiologists and PC physicians. The nurse case managers, who were the key care providers in this study, were able to empower their patients in symptom management, make adjustments to medications, and offer early referral if appropriate. Home care nurses are instrumental in coordinating care for patients immediately after hospital discharge, and providing early intervention when problems are detected. In order to further improve clinical outcome in the future, aligning financial incentives between specialties and across healthcare settings is important, particularly when building a service model in the delivery of care needs to extend from hospital to home.