Early palliative care in heart failure shows neutral effects across EF subtypes: an exploratory EPCHF secondary analysis.

Effect of early and systematic integration of palliative care in patients with advanced cancer: a randomised controlled trial

Erratum

Early integration of palliative care versus standard cardiac care for patients with heart failure (EPCHF): a multicentre, parallel, two-arm, open-label, randomised controlled trial

Background Although a 5-point change in Kansas City Cardiomyopathy Questionnaire (KCCQ) scores is widely recognized as representing a clinically meaningful change in symptoms and quality of life, it is not known how changes KCCQ scores relate to risk of hospitalization and death. Purpose To evaluate how changes in KCCQ summary scores relate to subsequent risk of hospitalization and death in a large cohort of patients with heart failure and reduced ejection fraction (HFrEF). Methods We used individual patient data from 3 HFrEF trials (ATMOSPHERE, PARADIGM-HF, and DAPA-HF) to examine the association between changes in KCCQ summary scores between baseline and 8-months and the subsequent risk of cardiovascular death or HF hospitalization, using Cox-proportional hazard models. Change in score was categorized as very small (>0 <5), small (> = 5 <10), moderate (> = 10 <20), and large (> = 20) points. We examined the KCCQ total symptom score (KCCQ-TSS), KCCQ clinical summary score (KCCQ-CSS), and KCCQ overall summary score (KCCQ-OSS). Results Among 15,892 participants with HFrEF, 1403 patients (8.8%) had a large deterioration in KCCQ score, 1688 (10.6%) a moderate deterioration, 1442 (9.1%) a small deterioration, 1527 (9.6%) a very small deterioration, and 2326 (14.6%) no deterioration. Conversely, 1836 patients (11.6%) had a very small improvement, 1732 (10.9%) a small improvement, 2202 (13.9%) a moderate improvement, and 1736 (10.9%) a large improvement. Patients with larger changes in KCCQ scores were older and more often female and had lower baseline summary scores and worse heart failure characteristics. Worsening heath status i.e., decrease in the KCCQ-TSS, was associated with a higher risk of the composite outcome (and each of its components), as well as all-cause mortality (Figure 1). On the contrary, improvements in KCCQ-TSS were not associated with better clinical outcomes (Figure 1). The findings were similar for 4-month changes of KCCQ-TSS, and changes in other KCCQ scores (KCCQ-CSS and KCCQ-OSS) at both 4 and 8-months. Conclusion Decreases (deterioration) in KCCQ summary scores during follow-up were associated with worse outcomes in patients with HFrEF but no association was seen between improvement in KCCQ scores and outcomes. These findings have potential implications for the interpretation of the effect of treatment on KCCQ scores.

The Palliative Care in Heart Failure Trial: Rationale and design

Palliative care improves quality of life in patients with heart failure. Whether men and women with heart failure derive similar benefit from palliative care interventions remains unknown. In a secondary analysis of the PAL-HF trial (Palliative Care in Heart Failure), we analyzed differences in quality of life among men and women with heart failure and assessed for differential effects of the palliative care intervention by sex. Differences in clinical characteristics and quality-of-life metrics were compared between men and women at serial time points. The primary outcome was change in Kansas City Cardiomyopathy Questionnaire score between baseline and 24 weeks. Among the 71 women and 79 men, there was a significant difference in baseline Kansas City Cardiomyopathy Questionnaire (24.5 versus 36.2, respectively; P=0.04) but not Functional Assessment of Chronic Illness Therapy-Palliative Care scale (115.7 versus 120.3; P=0.27) scores. Among those who received the palliative care intervention (33 women and 42 men), women's quality-of-life score remained lower than that of men after enrollment. Treated men's scores were significantly higher than those untreated (6-month Kansas City Cardiomyopathy Questionnaire, 68.0 [interquartile range, 52.6-85.7] versus 41.1[interquartile range, 32.0-78.3]; P=0.047), whereas the difference between treated and untreated women was not significantly different (P=0.39). Rates of death and rehospitalization, as well as the composite end point, were similar between treated and untreated women and men. In the PAL-HF trial, women with heart failure experienced a greater symptom burden and poorer quality of life as compared with men. The change in treated men's Kansas City Cardiomyopathy Questionnaire score between baseline and 24 weeks was significantly higher than those untreated; this trend was not observed in women. Thus, there may be a sex disparity in response to palliative care intervention, suggesting that sex-specific approaches to palliative care may be needed to improve outcomes. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT0158960.

Heart failure (HF) is a prevalent cause of hospital readmissions. Our study aims to determine the correlation between the Kansas City Cardiomyopathy Questionnaire (KCCQ) scores and 6-month readmission in our Southeast Asian population. We evaluated KCCQ-12 in a cohort of 180 patients at first post-discharge visit after a recent hospitalization for HF with reduced ejection fraction (HFrEF). Logistic regression was used to determine the predictive significance of the KCCQ scores for 6-month HF readmission. The selection of predictive parameters was performed using Stepwise Akaike Information Criterion (StepAIC). Out of 180 patients, 52 (29%) were readmitted for HF within 6 months. The mean KCCQ score was higher in the non-readmitted group (78.5) compared to the readmitted group (69.7, p = 0.0129). Multivariate analysis indicated a significant association between higher KCCQ scores (better health status) and lower HF readmission rates (adjusted OR = 0.929, p = 0.0255). The initial predictive model, using patient demographic data, had an AUC score of 0.64. Integrating KCCQ scores with demographics, length of stay (LOS), medical history and discharge medication variables raised the AUC score to 0.82. KCCQ scores recorded at first post-discharge encounter were found to have a significant relationship with 6-month readmissions in our cohort, suggesting that KCCQ scores can serve as an effective clinical indicator of 6 month readmissions.

Palliative Care in Heart Failure: Results of a Randomized, Controlled Clinical Trial

Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial

Healthcare providers' perceptions of palliative care in children with cancer influence care management, specifically that of its early integration. Thus, it is crucial to understand the perspectives of the providers on early integration of palliative care so that measures to create informed care decisions are based on reconciling their views. To explore the perceptions of paediatric oncology providers at the Children's Cancer Institute (CCI) in Lebanon regarding the integration of early paediatric palliative care (PPC) in the management of children with cancer. A qualitative descriptive research design with focus groups was used in a leading paediatric oncology setting. The thematic analysis yielded four themes: (1) healthcare providers understood palliative care as pain relief and psychological support mainly at the end of life; (2) the timing of integrating PPC is linked to end of life, advanced disease or treatment failure; (3) interdisciplinary collaboration is important for addressing patients' and families' needs effectively; and (4) communication with the child and family is one of the most difficult aspects of integrating PPC. This study demonstrated the perceptions of healthcare providers about early palliative care in paediatric oncology in Lebanon. It also highlighted the importance of interdisciplinary collaboration and effective communication with the child and family for better management of PPC.

Patient-reported and morbidity-mortality endpoints: can one have the best of both worlds?

Background: Atrial fibrillation (AF) is a prevalent condition with a major influence on patients’ quality of life, especially when blood glucose and heart rate are disrupted and systemic inflammation is present. Objective: This study aimed to compare Kansas City Cardiomyopathy Questionnaire (KCCQ) scores of diabetic patients by AF type and their correlations with different clinical and biological parameters. Material and methods: The retrospective study included 220 patients, from which only 200 were selected because of missing data. Patients were divided into three groups: paroxysmal AF (n = 49), persistent AF (n = 54), and permanent AF (n = 97). Demographic, clinical, and analytical data, echocardiographic parameters, heart rate, blood glucose, renal function, and inflammatory markers were compared between the three groups and their relationship with KCCQ scores. Results: The KCCQ score was significantly higher in patients with paroxysmal AF (69.50 ± 5.93), compared to persistent AF (56.92 ± 3.04) and permanent AF (42.28 ± 5.89), p < 0.001. In subanalyses, based on left ventricular ejection fraction (LVEF), the same trend was maintained, with lower KCCQ scores associated with more severe forms of AF. Significant negative correlations of the KCCQ score with blood glucose level (r = −0.2535, p = 0.0003), heart rate (r = −0.3071, p < 0.0001), and neutrophil–lymphocyte ratio (NLR) (r = −0.2395, p = 0.0006), and a positive correlation with glomerular filtration rate (GFR) (r = 0.4349, p < 0.0001) were identified. Conclusions: The type of atrial fibrillation significantly influences the quality of life assessed by the KCCQ score. Clinical and analytical parameters such as blood glucose, heart rate, systemic inflammation, and renal function significantly correlate with patients’ perception of health, indicating the importance of integrated management of AF.

Current study was to evaluate the effectiveness of nurse-led program in improving mental health status (MHS) and quality of life (QOL) in chronic heart failure (CHF) patients after an acute exacerbation. CHF patients were enrolled after informed consent was obtained and were assigned into the control and treatment group. Patients in the control group received standard care. In the treatment group, patients received standard care plus telehealth intervention including inquiring patients medical condition, providing feedbacks, counseling patients, and having positive and emotional talk with patients. At the third and sixth month after discharge, participants were called by registered nurses to assess Mental Health Inventory-5 (MHI-5) and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. Compared to the treatment group, patients in the control group were less likely to have educational attainment ≥ high school degree and have a married status, but were more likely to have diabetes. No significant differences in MHI-5 (68.5 ± 12.7 vs 66.9 ± 10.4) and KCCQ (70.6 ± 12.2 vs 68.7 ± 10.9) scores at baseline between the control and treatment groups were observed. There were significantly differences in MHI-5 (72.7 ± 15.6 vs 65.2 ± 11.4) and KCCQ score (74.2 ± 14.9 vs 66.4 ± 12.1) at 3 months follow-up between control and treatment groups. Nonetheless, at 6 months follow-up, although MHI-5 and KCCQ scores remained higher in the treatment group, there were no statistically significant differences (MHI-5: 65.4 ± 12.8 vs 61.4 ± 10.0; KCCQ: 65.1 ± 12.3 vs 61.9 ± 10.3). After multivariate regression analysis, not receiving nurse-led program were significantly associated with reduced MHI-5 (odds ratio [OR] 1.25% and 95% confidence interval [CI]: 1.14–1.60) and KCCQ (OR: 1.20% and 95% CI:1.11–1.54) scores. Nurse-led program is helpful to improve MHS and QOL in CHF patients after an acute exacerbation. However, these achievements are attenuated quickly after the nurse-led intervention discontinuation.

The nurse-led program is associated with a short-term improvement of mental health status (MHS) and quality of life (QOL) in patients with chronic heart failure (CHF). Nonetheless, the long-term effect of this program is undetermined. The aims of the current study were to evaluate the 1-year effects of the nurse-led program on MHS, QOL, and heart failure (HF) rehospitalization among patients with CHF.CHF patients in the control group received standard care, and patients in the treatment group received standard care plus telehealth intervention including inquiring patients’ medical condition, providing feedbacks, counseling and providing positive and emotional talk with the patients. At the third, sixth, and twelfth month's follow-up, patients were called by registered nurses to assess the Mental Health Inventory-5 (MHI-5) and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. HF rehospitalization was also assessed.A total of 300 patients were included and 46% (n = 138) of the patients were in the treatment group. There were no significant between-group differences in the MHI-5 and KCCQ scores at baseline. In the control group, the MHI-5 score was gradually decreased with follow-up and the score was significantly lower than that in the treatment group since the third month's follow-up (63.5 ± 10.6 vs 73.6 ± 10.3). Compared with the treatment group, KCCQ score was lower in the control group from the third month's follow-up (64.3 ± 10.6 vs 73.5 ± 12.3) until the end of the twelfth months’ follow-up (45.3 ± 11.2 vs 60.8 ± 11.1). During 12 months’ follow-up, the proportion of patients who experienced HF rehospitalization was lower in the treatment group (19.6% vs 24.1%). After adjusting for covariates, the utilization of the nurse-led program, and increase of MHI-5 and KCCQ scores were associated with reduced risk of HF rehospitalization.The nurse-led program is beneficial for the improvement of MHS and QOL for CHF patients, which might contribute to the reduction of HF rehospitalization.

Compared with standard care alone, early integration of specialist palliative care in the treatment of patients with advanced cancer offers significant benefit with respect of symptom control, healthrelated quality of life and survival. The early integration of specialist palliative care means that patients receive palliative care concurrent with, or shortly after, the diagnosis of advanced cancer. Using data from 2015 compiled from a large German statutory health insurance company (AOK Baden-Wuerttemberg) which insures 3.87 million people, we evaluated how many patients were identified with advanced metastatic cancer and at what point in time, if ever, general practitioners referred them to a specialist palliative home care team. The data were collected exclusively from general practices in the BadenWürttemberg province of Germany. Patients with advanced cancer where identified using all ICD-10 codes for cancer and the ICD-10 codes for metastases. Patients receiving care from a palliative care team were identified using the codes 01425 or 01426 of the German medical fee schedule. We identified 3,535 patients diagnosed with advanced cancer as having palliative care needs. 669 (18.9%) of these were referred to a specialist home care team. Of these, 302 (45.1%) where referred to a palliative care team on the day they were diagnosed but 367 (54.9%) were referred only at a later point in time. Two hundred and six (30.8%) patients had a delayed referral after 8 weeks or more and 153 (22.9%) after more than 12 weeks. Over half of the cancer patients in general practice who are referred for specialist palliative care are done so very late. General practitioners appear to need encouragement for the early integration of palliative care for patients with advanced cancer and to initiate early referrals to palliative care teams.