Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association.

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

Remote Follow-up in a Heart Failure Pragmatic Trial: Insights From the CONNECT-HF.

BACKGROUND: Randomized controlled trials typically require study-specific visits, which can burden participants and sites. Remote follow-up, such as centralized call centers for participant-reported or site-reported, holds promise for reducing costs and enhancing the pragmatism of trials. In this secondary analysis of the CONNECT-HF (Care Optimization Through Patient and Hospital Engagement For HF) trial, we aimed to evaluate the completeness and validity of the remote follow-up process. METHODS AND RESULTS: The CONNECT-HF trial evaluated the effect of a post-discharge quality-improvement intervention for heart failure compared to usual care for up to 1 year. Suspected events were reported either by participants or by health care proxies through a centralized call center or by sites through medical-record queries. When potential hospitalization events were suspected, additional medical records were collected and adjudicated. Among 5942 potential hospitalizations, 18% were only participant-reported, 28% were reported by both participants and sites, and 50% were only site-reported. Concordance rates between the participant/site reports and adjudication for hospitalization were high: 87% participant-reported, 86% both, and 86% site-reported. Rates of adjudicated heart failure hospitalization events among adjudicated all-cause hospitalization were lower but also consistent: 45% participant-reported, 50% both, and 50% site-reported. CONCLUSIONS: Participant-only and site-only reports missed a substantial number of hospitalization events. We observed similar concordance between participant/site reports and adjudication for hospitalizations. Combining participant-reported and site-reported outcomes data is important to capture and validate hospitalizations effectively in pragmatic heart failure trials.

Improving Hypertension Control in the Black Patient Population: A Quality Improvement Study of Workflow Redesign Using the Electronic Health Record to Integrate Self-Monitoring, Education, and Reporting.

BACKGROUND: Nearly half of American adults have hypertension (HTN), and non-Hispanic Black patients are diagnosed at a higher rate than others. LOCAL PROBLEM: Our local clinic population reflected disproportionate rates of uncontrolled HTN among Black patients. METHODS: A quality improvement pre-/postintervention design was used to evaluate an educational intervention to reduce blood pressure (BP) and improve self-monitoring of BP in Black patients using the Chronic Care Model. INTERVENTIONS: A team-based approach was used to redesign clinic workflows and patient education, prescribe self-paced videos from an electronic health record (EHR) patient portal, and provide home BP cuffs. RESULTS: Black participants (n = 79) improved viewing of prescribed videos (7.9% to 68.5%), knowledge scores (67.9 to 75.2), and mean systolic BP (-20.3 mm Hg; P > .001). CONCLUSIONS: This team-based approach enhanced patient engagement, self-monitoring skills, EHR-reported BP, and overall BP control for a cohort of Black patients with uncontrolled BP.

Timing of sedation and patient-reported pain outcomes during cardiac catheterization: Results from the UNTAP-intervention study.

BACKGROUND: Invasive cardiac catheterization (CC) temporarily increases pain, discomfort, and anxiety. Procedural sedation is deployed to mitigate these symptoms, though practice varies. Research evaluating peri-procedural patient-reported outcomes is lacking. METHODS AND RESULTS: We randomized 175 patients undergoing CC to short interval ([SI] group, <6 min) or long interval ([LI] group, ≥6 min) time intervals between initial intravenous sedation and local anesthetic administration. Outcomes included: (1) total pain medication use, (2) patient-reported and behaviorally assessed pain and (3) patient satisfaction during outpatient CC. Generalized linear mixed effect models were used to evaluate the impact of treatment time interval on total medication utilization, pain, and satisfaction. Among enrollees the mean age was 62 (standard deviation [SD] = 13.4), a majority were male (66%), white (74%), and overweight (mean body mass index = 28.5 [SD = 5.6]). Total pain medication use did not vary between treatment groups (p = 0.257), with no difference in total fentanyl (p = 0.288) or midazolam (p = 0.292). Post-treatment pain levels and nurse-observed pain were not statistically significant between groups (p = 0.324 & p = 0.656, respectively. No significant differences with satisfaction with sedation were found between the groups (p = 0.95) Patient-reported pain, satisfaction and nurse-observed measures of pain did not differ, after adjustment for demographic and procedural factors. Analyses of treatment effect modification revealed that postprocedure self-reported pain levels varied systematically between individuals undergoing percutaneous coronary intervention (PCI) (SI = 2.2 [0.8, 3.6] vs. LI = 0.7 [-0.6, 2.0]) compared with participants not undergoing PCI (SI = 0.4 [-0.8, 1.7] vs. LI = 0.7 [-0.3, 1.6]) (p = 0.043 for interaction). CONCLUSION: No consistent treatment differences were found for total medication dose, pain, or satisfaction regardless of timing between sedation and local anesthetic. Treatment moderations were seen for patients undergoing PCI. Further investigation of how procedural and individual factors impact the patient experience during CC is needed.

Evidence-Based Clinical Decision Support to Improve Care for Patients Hospitalized With Acute Myocardial Infarction.

Clinical decision support in the EHR is an innovation that can support guideline adherence in acute myocardial infarction. Cardiac rehabilitation referral and left ventricular systolic function assessment are part of evidence-based clinical practice guidelines associated with reduced morbidity and mortality following acute myocardial infarction. Effective clinical decision support is sustained by evidence-based principles for design and implementation. This quality improvement project evaluated the impact of practice advisories designed using principles of effective clinical decision support design to improve performance of left ventricular systolic function assessment and ambulatory referral to cardiac rehabilitation for patients hospitalized with acute myocardial infarction. Performance in cardiac rehabilitation referral and left ventricular systolic function assessment was measured for a 3-month interval pre- and post-intervention. Pre-implementation, cardiac rehabilitation referral or valid documented reason for non-referral was 80.3%. Rehabilitation referral or documented valid reason for non-referral increased to 98.4% post-implementation ( P < .001). Left ventricular systolic function assessment increased from 94.2% to 100% following clinical decision support implementation ( P = .120). This quality improvement project supports the positive impact of effective clinical decision support design and implementation to improve outcomes for patients hospitalized with acute myocardial infarction.

A Randomized Controlled Trial of Mobile Health Intervention in Patients With Heart Failure and Diabetes.

BACKGROUND: Mobile health (mHealth) platforms can affect health behaviors but have not been rigorously tested in randomized trials. OBJECTIVES: We sought to evaluate the effectiveness of a pragmatic mHealth intervention in patients with heart failure (HF) and diabetes (DM). METHODS: We conducted a multicenter randomized trial in 187 patients with both HF and DM to assess an mHealth intervention to improve physical activity and medication adherence compared to usual care. The primary endpoint was change in mean daily step count from baseline through 3 months. Other outcomes included medication adherence, health-related quality of life and metabolomic profiling. RESULTS: The mHealth group had an increase in daily step count of 151 steps/day at 3 months, whereas the usual-care group had a decline of 162 steps/day (least squares mean between-group difference = 313 steps/day; 95% CI: 8 619; P = 0.044). Medication adherence, measured using the Voils Adherence Questionnaire, did not change from baseline to 3 months (LS-mean change -0.08 in mHealth vs -0.15 in usual care; P = 0.47). The mHealth group had an improvement in Kansas City Cardiomyopathy Questionnaire Overall Summary Score compared to the usual-care group (LS-mean difference = 5.5 points, 95% CI: 1.4, 9.6; P = 0.009). Thirteen metabolites, primarily medium- and long-chain acylcarnitines, changed differently between treatment groups from baseline to 3 months (P < 0.05). CONCLUSIONS: In patients with HF and DM, a 3-month mHealth intervention significantly improved daily physical activity, health-related quality of life and metabolomic markers of cardiovascular health but not medication adherence. CONDENSED ABSTRACT: Heart failure (HF) and diabetes (DM) have overlapping biological and behavioral risk factors. We conducted a multicenter randomized, clinical trial in 187 patients with both HF (regardless of ejection fraction) and DM to assess whether an mHealth intervention could improve physical activity and medication adherence. The mHealth group had an increase in mean daily step count and quality of life but not in medication adherence. Medium- and long-chain acylcarnitines changed differently in treatment groups from baseline to 3 months (P < 0.05). These data have important implications for designing effective lifestyle interventions in HF and DM.

Polypharmacy in Palliative Care for Advanced Heart Failure: The PAL-HF Experience.

BACKGROUND: Palliative care (PC) in advanced heart failure (HF) aims to improve symptoms and quality of life (QOL), in part through medication management. The impact of PC on polypharmacy (>5 medications) remains unknown. METHODS AND RESULTS: We explored patterns of polypharmacy in the Palliative Care in HF (PAL-HF) randomized controlled trial of standard care vs interdisciplinary PC in advanced HF (N = 150). We describe differences in medication counts between arms at 2, 6, 12, and 24 weeks for HF (12 classes) and PC (6 classes) medications. General linear mixed models were used to evaluate associations between treatment arm and polypharmacy over time. The median age of the patients was 72 years (interquartile range 62-80 years), 47% were female, and 41% were Black. Overall, 48% had ischemic etiology, and 55% had an ejection fraction of 40% or less. Polypharmacy was present at baseline in 100% of patients. HF and PC medication counts increased in both arms, with no significant differences in counts by drug class at any time point between arms. CONCLUSIONS: In a trial of patients with advanced HF considered eligible for PC, polypharmacy was universal at baseline and increased during follow-up with no effect of the palliative intervention on medication counts relative to standard care.

The Association of Digital Health Application Use With Heart Failure Care and Outcomes: Insights From CONNECT-HF.

BACKGROUND: It is unknown whether digital applications can improve guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure trial (CONNECT-HF) included an optional, prospective ancillary study of a mobile health application among patients hospitalized due to HFrEF. Digital users were matched to nonusers from the usual-care group. Coprimary outcomes included change in opportunity-based composite HF quality scores and HF rehospitalization or all-cause mortality. Among 2431 patients offered digital applications across the United States, 1526 (63%) had limited digital access or insufficient data, 425 (17%) were digital users, and 480 (20%) declined use. Digital users were similar in age to those who declined use (mean 58 vs 60 years; P = 0.031). Digital users (n = 368) vs matched nonusers (n = 368) had improved composite HF quality scores (48.0% vs 43.6%; + 4.76% [3.27-6.24]; P = 0.001) and composite clinical outcomes (33.0% vs 39.6%; HR 0.76 [0.59-0.97]; P = 0.027). CONCLUSIONS: Among participants in the CONNECT-HF trial, use of digital applications was modest but was associated with higher HF quality-of-care scores, including use of GDMT and better clinical outcomes. Although cause and effect cannot be determined from this study, the application of technology to guide GDMT use and dosing among patients with HFrEF warrants further investigation.

Health System-Level Performance in Prescribing Guideline-Directed Medical Therapy for Patients With Heart Failure With Reduced Ejection Fraction: Results From the CONNECT-HF Trial.

BACKGROUND: Health system-level interventions to improve use of guideline-directed medical therapy (GDMT) often fail in the acute care setting. We sought to identify factors associated with high performance in adoption of GDMT among health systems in CONNECT-HF. METHODS AND RESULTS: Site-level composite quality scores were calculated at discharge and last follow-up. Site performance was defined as the average change in score from baseline to last follow-up and analyzed by performance tertile using a mixed-effects model with baseline performance as a fixed effect and site as a random effect. Among 150 randomized sites, the mean 12-month improvement in GDMT was 1.8% (-26.4% to 60.0%). Achievement of 50% or more of the target dose for angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, and beta-blockers at 12 months was modest, even at the highest performing sites (median 29.6% [23%, 41%] and 41.2% [29%, 50%]). Sites achieving higher GDMT scores had care teams that included social workers and pharmacists, as well as patients who were able to afford medications and access medication lists in the electronic health record. CONCLUSIONS: Substantial gaps in site-level use of GDMT were found, even among the highest performing sites. The failure of hospital-level interventions to improve quality metrics suggests that a team-based approach to care and improved patient access to medications are needed for postdischarge success.

Care Coordination Processes in Transitional Care for Patients With Heart Failure: An Integrative Review Through a Social Network Lens.

BACKGROUND: Transitional care components are well studied, but their coordination has not been systematically reviewed. Viewing transitional care through a social network framework can focus attention on processes leading to information and relationship transferal to ensure continuity and may lead to new strategies to improve transitional care. OBJECTIVE: The aim of this study was to examine care coordination processes in transitional care interventions for older adults with heart failure by integrating a social network analysis approach. METHODS: PubMed, Scopus, and CINAHL were searched to capture transitional care interventions ( a ) involving care coordination for older adults with heart failure transitioning from hospital to home and ( b ) published in the United States from 2010 to 2020. Study characteristics, intervention characteristics, and care coordination processes (ie, participants, interactions among participants, and their characteristics) were extracted. RESULTS: In 17 studies reviewed, the number of individual roles involved in care coordination varied from 3 to 32. Nurses and pharmacists were the most common interventionists. Six studies involved informal caregivers. In-person interactions were most common among individuals within settings; interactions across settings were typically assisted by technology. Despite high variability among the individuals and interactions involved, a common triadic process was found through which interventionists, patients, and primary care providers or outpatient cardiologists aimed to facilitate the transfer of information and care relationships from hospital to community. CONCLUSIONS: High variability in transitional care is likely because the processes are highly relational. Using a network analysis may help uncover the relational structures and processes underlying transitional care to inform intervention development.

A Qualitative Descriptive Study of Nurse Manager Decision-Making Associated With RN Hiring.

OBJECTIVE: To explore the practices and self-confidence of nurse manager (NM) decision-making related to evaluating RN hiring needs. BACKGROUND: Evidence-based hiring strategies to sustain workforce stability were identified as a gap in the literature. Locally, inconsistencies in the method that NMs use to determine how many RNs to hire and at what frequency to hire them were observed, posing a threat to strategic workforce planning. METHODS: Using a mixed-methods, qualitative descriptive design, researchers used in-depth interviews and surveys to assess current practices and NM confidence related to evaluating hiring needs. RESULTS: The overarching theme among the 10 participants was false confidence. Subthemes reflected the dissonance in confidence and high variability in the hiring process. NM stress, time spent, and confidence were not correlated with years' experience. CONCLUSIONS: NMs experience stress, spend excessive time, and use varying approaches to evaluate hiring needs. Years of managerial experience are unrelated to practical skills or level of confidence in hiring decision-making.

Feasibility of Electronic Health Record Integration of a SMART Application to Facilitate Patient-Provider Communication for Medication Management.

Increased treatment complexity in patients with diabetes contributes to medication nonadherence. Patient portals that are accessible through electronic health records may offer improved patient-provider communication and better medication management in patients with diabetes and uncontrolled hypertension. We conducted a prospective, mixed-methods evaluation of the Duke PillBox application, a SMART-on-FHIR medication management application integrated into the electronic health record patient portal. Adults with active portal status, diabetes, and uncontrolled hypertension participated in a usability/feasibility survey and communicated with a pharmacist via the portal-based application who conducted medication reconciliation and discussed medication indications, side effects, and barriers to use with patients. Of the eligible patients (n = 285), 29 (10%) were interested, and 12 (8%) participated. Challenges to usability were due to the electronic health record-portal communication interface (91%), browser access and compatibility (55%), and persistent lists of unused medications in the electronic health record (27%). The findings of this study suggest that electronic health record-integrated medication applications are desirable as indicated in patient interactions at the outset and conclusion of the study. Persistent challenges included electronic health record integration, interoperability, user interface, and browser connectivity for both patients and providers.

A scoping review of outcomes of operational success for nurse scientists in clinical practice settings.

BACKGROUND: The nurse scientist in the clinical setting is a role that has evolved over recent decades to encompass the concomitant development of personal research programs and the facilitation of staff and advanced practice nurse research in health care settings. However, the definition, operationalization, and measures of success are extremely variable. PURPOSE: To identify the defining features and characteristics of the nurse scientist role in clinical practice settings as represented in the existing literature. METHODS: We conducted a scoping review using PubMed and CINAHL databases. We initially identified a total of 3345 references from 1976 to June 2020, 217 of which were published from 2005-2020. We used the Joanna Briggs Institute (JBI) framework to explore the state of the science of the role of nurse scientists in practice settings. DISCUSSION: Approximately 100 articles met the criteria for full-text analysis, and the final review consisted of 20 descriptive analytic studies addressing the nurse scientist role definition, operationalization, and outcome measures. CONCLUSION: Findings suggest that nurse scientist roles serve to promote health system success through a host of research-focused activities that conceivably contribute to improved patient care outcomes. Work is needed to support the cost of requisite resources and infrastructure and to increase acceptance of the role as part of a tenure-earning track in academic settings that also stand to benefit.

Moving nursing innovation to prime time through the use of creative partnerships.

Nurses are well-positioned to solve many problems in healthcare through engagement in innovation. Support from healthcare organizations to facilitate creative partnerships may accelerate nurses' ability to innovate and improve job satisfaction. The value of creative partnerships is rooted in the diversity of experiences and skillsets of each project team member. While nurses may be content experts and key stakeholders, they often lack experience with project management, information technology, product development, and other important skills. We describe the use of co-creation approaches in creative partnerships with diverse stakeholders to enhance the ability of nurse-led project teams to build valuable and sustainable products or services.

Evaluation of a proactive hiring model to achieve workforce stability in the intensive care unit.

AIM: The purpose was to evaluate an innovative Prospective Hiring Equation to determine registered nurse hiring needs. BACKGROUND: The American Organization for Nursing Leadership identifies human resource management as a competency for nurse managers, yet calculations to determine when and how many registered nurses to hire are not readily available. METHODS: We implemented an educational intervention to teach nurse mangers the Prospective Hiring Equation. We evaluated the processes (adoption and confidence) and outcomes (vacancy rates) using a pre-evaluation/postevaluation design in a single cohort of nurse managers (n = 9). We used a statistical process control chart to depict mean differences in vacancy rate at baseline and 6-month postimplementation. RESULTS: Participants (n = 9) were on average 43 years' old, female, and had 2.94 (SD = 2.66) years' of nurse manager experience. Following implementation of the intervention, the combined vacancy rates of the intensive care units improved by 11.8% (SD = 7), and use of agency nurses decreased by 42.5% (premedian = 7.2, interquartile ratio = 3.6, 10.8; postmedian = 1.8, interquartile ratio 0.9, 8.55). CONCLUSIONS: The Prospective Hiring Equation may be a useful tool to improve nurse managers human resource management competencies. IMPLICATIONS FOR NURSING MANAGEMENT: The Prospective Hiring Equation may help nurse managers improve accuracy when evaluating hiring needs.

The impact of nurse staffing on falls performance within a health care system: A descriptive study.

AIM: The purpose of this study was to examine the impact of nurse staffing on inpatient falls performance across a multi-hospital system. BACKGROUND: Evidence to support which staffing variables influence fall performance so that health care organizations can better allocate resources is lacking. METHOD: A descriptive study design was used to analyse the impact of nurse staffing and falls performance, with units dichotomized as either high or low performing based on national benchmarking data. The impact was evaluated using 10 nurse staffing variables. RESULTS: A total of nine units were included (five high and four low performing). Higher performing units showed less use of sitters and travellers, had fewer overtime hours worked by nurses, and employed more expert-level clinical nurses and combined nursing assistant/health unit coordinator positions, than lower performing units. CONCLUSION: Findings provide evidence of how staffing variables affect a unit's falls performance. While significant relationships were found, further evaluation is needed to explore the relationship of staffing variables and quality outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers may consider trying to reduce use of sitters and travellers, and utilize innovative staffing models, such as using combined nursing assistant/health unit coordinator positions, to help improve their falls performance.

Evaluating the efficacy of telephone-based outreach in addressing hypertension control among black men with severe hypertension: An observational study.

BACKGROUND: The high prevalence of uncontrolled hypertension (systolic blood pressure [SBP] ≥140 mmHg or diastolic blood pressure [DBP] ≥90 mmHg) in Black patients represents a significant racial health disparity in the United States. AIMS: This study evaluated the efficacy of a telephone-based strategy for inviting high-risk patients with severe hypertension to weekly self-management education classes. Further, the study assessed how the outreach intervention correlated with relevant quality improvement outcomes, including improved blood pressure and primary care follow-up among our clinic population of Black men with severe hypertension. METHODS: A cohort of 265 Black men aged ≥18 years with SBP ≥160 mmHg or DBP ≥100 mmHg at the most recent clinic visit were identified using Epic reports formatted for Federal Uniformed Data Set annual reporting. Telephone outreach was used to invite the cohort to attend weekly in-person classes facilitated by various healthcare professionals. Logistic regression was performed to determine the associations between being reached by phone with (1) class attendance and (2) follow-up appointment attendance. RESULTS: Most of the Black men were single (57.4%, n = 152), 49.1% had history of alcohol or substance use (n = 130), and 35.8% (n = 95) was uninsured. The average age was 55.6 years (SD = 11.6). After controlling for sociodemographic factors, being reached by phone was significantly associated with an increased likelihood of patient attendance at follow-up appointments (OR = 1.91, p = .038) but not with class attendance (OR = 2.45, p = .155). Patients who attended a follow-up appointment experienced significant reductions in both SBP and DBP at 9 months. LINKING EVIDENCE TO ACTION: Telephone outreach was labor-intensive but effective in keeping under-resourced patient populations engaged in primary care. Future work should aim to develop more efficient strategies for engaging high-risk patients in self-monitoring education to manage hypertension.

Patient expectations and preferences for community-based hypertension classes with implications for action.

BACKGROUND: Uncontrolled hypertension disproportionately affects Black men. Patient engagement with health promotion and health behavior programs for hypertension control is low. We held evidence-based hypertension classes at a Federally Qualified Health Center. AIMS: The aim of this project was to elicit patient preferences and expectations for community-based hypertension classes. METHODS: Group hypertension classes were held at a Federally Qualified Health Center. The priority population was Black men with hypertension. Semi-structured interviews were conducted with the group class attendees. Two independent coders performed content analysis using field notes from the interviews. RESULTS: Seven group class attendees were interviewed. Six interviewees were Black males, one was a Black female, and the mean age was 65.7 years. Content analysis of the interview field notes revealed five content areas: (1) Recommendation of Group Classes to a Friend, (2) Expectations for the Group Classes, (3) Reasons for Continued Attendance, (4) Lifestyle Changes and Adopting the Group Class Lessons, and (5) Feedback and Recommendations to Improve Group Classes. Findings suggest that creating a cultural context in which open, transparent discussion of blood pressure occur can be achieved. Thus, regarding acceptability, classes fulfilled and often exceeded the attendees' expectations and needs. LINKING EVIDENCE TO ACTION: Our findings suggest that community-based group classes are a viable intervention to contribute toward addressing the disparity of hypertension control among Black men. When designing peer-group interventions, taking patient preferences and expectations into account increases the effectiveness of these interventions. The qualitative narrative provided in this paper contributes to the development of similar community-based group classes for the management of severe hypertension.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association.

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study (Data Supplement) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

The Cost-Effectiveness of Palliative Care: Insights from the PAL-HF Trial.

BACKGROUND: In a randomized control trial, Palliative Care in Heart Failure (PAL-HF) improved heart failure-related quality of life, though cost-effectiveness remains unknown. The aim of this study was to evaluate the cost-effectiveness of the PAL-HF trial, which provided outpatient palliative care to patients with advanced heart failure. METHODS AND RESULTS: Outcomes for usual care and PAL-HF strategies were compared using a Markov cohort model over 36 months from a payer perspective. The model parameters were informed by PAL-HF trial data and supplemented with meta-analyses and Medicare administrative data. Outcomes included hospitalization, place of death, Medicare expenditures, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Simulated mortality rates were the same for PAL-HF and usual care cohorts, at 89.7% at 36 months. In the base case analysis, the PAL-HF intervention resulted in an incremental gain of 0.03 QALYs and an incremental cost of $964 per patient for an incremental cost-effectiveness ratio of $29,041 per QALY. In 1-way sensitivity analyses, an intervention cost of up to $140 per month is cost effective at $50,000 per QALY. Of 1000 simulations, the PC intervention had a 66.1% probability of being cost effective at a $50,000 willingness-to-pay threshold assuming no decrease in hospitalization. In a scenario analysis, PAL-HF decreased payer spending through reductions in noncardiovascular hospitalizations. CONCLUSIONS: These results from this single-center trial are encouraging that palliative care for advanced heart failure is an economically attractive intervention. Confirmation of these findings in larger multicenter trials will be an important part of developing the evidence to support more widespread implementation of the PAL-HF palliative care intervention.