SWAP-HF: Palliative care initiative may improve quality of care for patients with advanced HF

Issue: November 2016

ORLANDO, Fla. — Early initiation of goals such as care conversations with social workers may lead to improvements in prognostic understanding and quality of care, according to findings presented at the Heart Failure Society of America Scientific Assembly.

According to the results of the SWAP-HF trial the approach may be a useful, low-cost option for patients with advanced HF.

“Patients nearing the end of life, we can all agree, should receive treatments that match their preference and goals for care,” Akshay Desai, MD, MPH, from the cardiovascular division of Brigham and Women’s Hospital, said in a late-breaking clinical trial presentation. “These sort of palliative care considerations are often overlooked or introduced quite late in the disease process.”

Researchers conducted a pilot study, in which 50 patients (median age, 72 years; 21 women) hospitalized with acute decompensated HF with more than one risk factor for poor prognosis were randomly assigned to receive a structured social worker-led palliative care program or the usual care. Most patients (82%) had been hospitalized for HF within 12 months prior to enrollment.

The risk factors for poor prognosis were age at least 80 years, estimated glomerular filtration rate < 45 mL/min/1.73m², systolic BP 100 mm Hg, serum sodium 130 meq/L, cardiac index < 2 L/min/m² or serious non-CV illness.

The palliative care program, supervised by a palliative care physician and managed by a social worker, included a structured evaluation of prognostic understanding, end-of-life preferences, symptom burden, and quality of life, according to the researchers. This information was given to treating clinicians and there was longitudinal follow up in the ambulatory setting.

Primary outcomes at 6 months were the proportion of patients with physician-level documentation of advanced care preferences and the degree of alignment between patient and physician expectations of prognosis.

Secondary outcomes included comparisons between the two cohorts of health care utilization, as well as depression, anxiety and quality-of-life scores.

When asked at baseline if they would be surprised if death of patients would occur within 12 months, 64% of physicians said that they would not be surprised, but 54% of patients said they anticipated a lifespan greater than 5 years and 28% foresaw a lifespan of over 10 years. In addition, 66% of patients said they would like to be informed if their physician believed their life expectancy was less than 1 year.

At 6 months, nearly 38% of the patients in the study had died (n=19), including 39% in the intervention group and 38% in the control group, Desai said.

Any documentation of advanced care preferences occurred for 65% of those in the intervention group and 33% of those in the control group (P = .02) at 6 months, while documentation of medical orders for life-sustaining treatment, critical care and hospice occurred for 58% of those in the intervention group and 20% of controls (P = .1), Desai said.

Although patient and physician expectations of prognosis are often misaligned, according to Desai, patients allocated to the social worker-led intervention were more likely to change their baseline prognostic assessment to more closely follow the physician’s assessment (94% vs. 26%; P < .001).

There were no significant differences between the groups in measures of depression, anxiety, quality of life or spirituality, Desai said.

“Training and empowering social workers to initiate goals of care conversations that evolve from the inpatient to the outpatient setting may improve physician engagement in palliative care concerns and the overall quality of care of advanced HF patients,” Desai said. “Although more comprehensive, multidisciplinary palliative care interventions may also be effective,” Desai said. “This focused approach may represent a cost-effective and scalable method for shepherding limited specialty resources to enhance the delivery of patient-centered care.”– by Dave Quaile

Reference:

O’Donnell AE, et al. Late-breaking Clinical Trials. Presented at: Heart Failure Society of America Scientific Assembly; Sept. 17-20, 2016; Orlando, Fla.

Disclosure: Desai reports no relevant financial disclosures.