Early Palliative Care Consultation Reduces Length Of Stay And Cost In Patients Hospitalized With Acute Decompensated Heart Failure

Abstract

Background Prolonged length of stay (LOS) in patients hospitalized with acute decompensated heart failure (ADHF) has been associated with increased health care costs and poor outcomes, as well as reduced quality of life and fewer days spent at home in patients with advanced HF. As a result, initiatives to reduce LOS have become a priority. Palliative care consults (PCC) have been associated with reduced length of stay and lower costs, with early PCC having the greatest impact. Emerging data has supported this strategy in non-cancer diagnoses. In this study, we investigate the effect of early vs. late PCC on LOS in patients with ADHF. Methods A retrospective chart review was performed. Patients admitted to the inpatient HF unit at St Francis Hospital between May and December 2020 with a primary diagnosis of ADHF were included. A best practice advisory is triggered in the EMR at the time of admission for patients with 3 or more HF admissions within the past 6 months or with PCC during a prior admission. Patients with PCC during admission were identified and divided into early PCC (within 3 days of admission), and late PCC (> 3 days into admission). The primary outcome was LOS. Results A total of 147 patients were included in the analysis, the average age was 76 years. Of these patients, 45% were female, 60% were white, 25% were black, and 13% were Hispanic. The majority (93%) were Medicare, Medicaid, or Medicare managed care. Early PCC was performed in 103 patients. Patients with early PCC had a trend towards older age (78 yrs. vs 72 yrs., p= 0.07). When corrected for other predictors of LOS, patients with early PCC had a significantly shorter LOS compared to those with late PCC (5.2 days vs 9.7 days, p= <0.001, Figure 1). There was no difference in in-hospital mortality. The patients with the highest severity of illness had the highest LOS when controlled for other covariates (8.6 days vs. 6.9 days, p= <0.001), and were least likely to have early PCC (p= 0.046). As the proportion of patients with early PCC increased, the median LOS decreased. Conclusions In this study, early PCC was associated with decreased LOS in patients admitted to an inpatient HF unit for ADHF. Although most likely to benefit from early PCC, the patients with the most severe illness were least likely to have palliative care involved early in their stay. For patients with HF and multiple admissions, early PCC should be considered. Further benefits of early palliative care involvement in ADHF should be a focus of future studies. Prolonged length of stay (LOS) in patients hospitalized with acute decompensated heart failure (ADHF) has been associated with increased health care costs and poor outcomes, as well as reduced quality of life and fewer days spent at home in patients with advanced HF. As a result, initiatives to reduce LOS have become a priority. Palliative care consults (PCC) have been associated with reduced length of stay and lower costs, with early PCC having the greatest impact. Emerging data has supported this strategy in non-cancer diagnoses. In this study, we investigate the effect of early vs. late PCC on LOS in patients with ADHF. A retrospective chart review was performed. Patients admitted to the inpatient HF unit at St Francis Hospital between May and December 2020 with a primary diagnosis of ADHF were included. A best practice advisory is triggered in the EMR at the time of admission for patients with 3 or more HF admissions within the past 6 months or with PCC during a prior admission. Patients with PCC during admission were identified and divided into early PCC (within 3 days of admission), and late PCC (> 3 days into admission). The primary outcome was LOS. A total of 147 patients were included in the analysis, the average age was 76 years. Of these patients, 45% were female, 60% were white, 25% were black, and 13% were Hispanic. The majority (93%) were Medicare, Medicaid, or Medicare managed care. Early PCC was performed in 103 patients. Patients with early PCC had a trend towards older age (78 yrs. vs 72 yrs., p= 0.07). When corrected for other predictors of LOS, patients with early PCC had a significantly shorter LOS compared to those with late PCC (5.2 days vs 9.7 days, p= <0.001, Figure 1). There was no difference in in-hospital mortality. The patients with the highest severity of illness had the highest LOS when controlled for other covariates (8.6 days vs. 6.9 days, p= <0.001), and were least likely to have early PCC (p= 0.046). As the proportion of patients with early PCC increased, the median LOS decreased. In this study, early PCC was associated with decreased LOS in patients admitted to an inpatient HF unit for ADHF. Although most likely to benefit from early PCC, the patients with the most severe illness were least likely to have palliative care involved early in their stay. For patients with HF and multiple admissions, early PCC should be considered. Further benefits of early palliative care involvement in ADHF should be a focus of future studies.