Factors Associated With Early Palliative Care Among Patients With Heart Failure.

Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.

Trends in Palliative Care Utilization in Deceased Veterans With Heart Failure.

Background: Specialist-level palliative care in the final days does not allow time to alleviate symptoms and suffering. This analysis examined the change in the time from initial specialty-level palliative care to death among Veterans with heart failure. Methods: This retrospective cohort study examined Veterans with a diagnosis of heart failure (HF) who died between 2011 and 2021. We examined the decedents from each year as a separate cohort. The primary outcome was time from specialty-level palliative care (SPC) encounter to death in the year death occurred. Results: Of the cohort (n = 232,079), 56.5% did not receive SPC. Specialist-level palliative care >90 days before death more than doubled from 10.1% (2011) to 26.2% (2021), and Specialist-level palliative care in the last day of life was cut from 2.5% to 0.9%. Conclusion: For Veterans with HF, specialist-level palliative care moved earlier in the disease course and has a substantial growth opportunity.

Impact of Geriatric Trauma Co-Management on 1-Year Mortality in Older Adults with Multiple Rib Fractures.

BACKGROUND: Rib fractures in older adults are associated with higher morbidity and mortality. Geriatric trauma co-management programs have looked at in-hospital mortality but not long-term outcomes. METHODS: A retrospective study of multiple rib fracture patients 65 years and older (n=357), admitted from September 2012 to November 2014 comparing Geriatric trauma co-management (GTC) vs Usual Care by trauma surgery (UC). The primary outcome was 1-year mortality. RESULTS: 38.9% (139) were cared for by GTC. Compared to the UC, GTC patients were older (81.6±8.6 years vs 79±8.5) and had more comorbidities (Charlson 2.8±1.6 vs 2.2±1.6). GTC patients had 46% less chance of dying in 1-year compared to UC (HR 0.54, 95% CI [0.33-0.86]).  Conclusions: GTC showed a significant reduction in 1-year mortality even though patients were overall older and more comorbid. This shows multidisciplinary teams are crucial to patient outcomes and should continue to be further explored.

Disparities in Utilization of Palliative Care in Patients Experiencing Homelessness.

BACKGROUND: Patients experiencing homelessness have increased disease burden, increased severity of illness, and increased barriers to accessing care. The provision of high-quality palliative care is therefore essential for this population. State of Homelessness: 18 out of every 10,000 people in the US and 10 out of every 10,000 Rhode Islanders (down from 12 in 2010) experience homelessness. Conceptual Model: High-quality palliative care for patients experiencing homelessness requires a foundation of patient-provider trust, well-trained interdisciplinary teams, coordinated transitions of care, community support, integrated healthcare systems, and comprehensive population and public health measures. CONCLUSIONS: Improving access to palliative care for those experiencing homelessness requires an interdisciplinary approach at all levels from individual providers to broader public health policies. A conceptual model rooted in patient-provider trust has the potential to address high-quality palliative care access disparities for this vulnerable population.

Utilization of Palliative Care in Veterans Admitted With Heart Failure Experiencing Homelessness.

CONTEXT: Patients experiencing housing insecurity have numerous barriers affecting their utilization of medical care. OBJECTIVES: Determine if housing insecurity is associated with palliative care (PC) encounters and hospice services in patients with heart failure who receive care in United States Veterans Affairs (VA) medical centers. METHODS: This retrospective study included inpatients in VA hospitals with a primary diagnosis of congestive heart failure from 2010 to 2020. Housing stability was collected from coding and separated into three cohorts: at risk for homelessness, experiencing homelessness, and stably housed. The primary outcome was a PC encounter during admission and the stably housed cohort was used as the analytic reference. Inverse-probability-weighting (IPTW) was calculated to adjust the likelihood of receiving PC during the index admission. RESULTS: Seventy thousand eight hundred fourty nine veterans were identified. Veterans were identified as at risk for homelessness (n=4039, 5.7%), experiencing homelessness (n=1967, 2.8%) and stably housed (n=64,843, 91.5%). PC was delivered to veterans at risk for homelessness (n=484, 12.0%), veterans experiencing homelessness, (n=161, 8.2%) and patients with stable housing (n=6249, 9.6%). Relative to the stably housed and adjusted for IPTW, those at risk for homelessness received PC services similarly (adjusted OR=1.06, 95% CI 0.94,1.19) and those experiencing homelessness were at lower odds of receiving PC services (adjusted OR=0.62, 95% CI 0.52,0.75). CONCLUSION: Housing stability may be a factor in Veterans receiving PC during hospitalization for heart failure. While the logistical challenges of delivering PC and hospice to people experiencing homelessness are daunting, advocating for these services shows commitment to reducing suffering in life-limiting Illness.

Racial Differences in Burdensome Transitions in Heart Failure Patients with Palliative Care: A Propensity-Matched Analysis.

Background: Examining racial disparities in the treatment of heart failure (HF) patients and the effects of palliative care (PC) consultation is important to developing culturally competent clinical behaviors. Objective: To compare burdensome transitions for Black and White Veterans hospitalized with HF after PC consultation. Participants: This retrospective study evaluated Veterans admitted for HF to Veterans Administration hospitals who received PC consultation from October 2010 through August 2017. Methods: We propensity-matched Black to White Veterans using demographic, comorbidity, clinical, hospital, and survival time data. Results: Propensity matching of our cohort (n = 5638) yielded 796 Black and White Veterans (total n = 1592) who were well-matched on observed variables (standard mean difference <0.15 for all variables). Matched Black Veterans had more burdensome transitions than White Veterans (n = 218, 27.4% vs. n = 174, 21.9%; p = 0.011) over the six-month follow-up period. Conclusions: This propensity-matched cohort found racial differences in burdensome transitions among admitted HF patients after PC consultation.

Decreased fetal size is associated with beta-cell hyperfunction in early life and failure with age.

OBJECTIVE: Low birth weight is associated with diabetes in adult life. Accelerated or "catch-up" postnatal growth in response to small birth size is thought to presage disease years later. Whether adult disease is caused by intrauterine beta-cell-specific programming or by altered metabolism associated with catch-up growth is unknown. RESEARCH DESIGN AND METHODS: We generated a new model of intrauterine growth restriction due to fatty acid synthase (FAS) haploinsufficiency (FAS deletion [FASDEL]). Developmental programming of diabetes in these mice was assessed from in utero to 1 year of age. RESULTS: FASDEL mice did not manifest catch-up growth or insulin resistance. beta-Cell mass and insulin secretion were strikingly increased in young FASDEL mice, but beta-cell failure and diabetes occurred with age. FASDEL beta-cells had altered proliferative and apoptotic responses to the common stress of a high-fat diet. This sequence appeared to be developmentally entrained because beta-cell mass was increased in utero in FASDEL mice and in another model of intrauterine growth restriction caused by ectopic expression of uncoupling protein-1. Increasing intrauterine growth in FASDEL mice by supplementing caloric intake of pregnant dams normalized beta-cell mass in utero. CONCLUSIONS: Decreased intrauterine body size, independent of postnatal growth and insulin resistance, appears to regulate beta-cell mass, suggesting that developing body size might represent a physiological signal that is integrated through the pancreatic beta-cell to establish a template for hyperfunction in early life and beta-cell failure with age.