4027 — Improving Health Status in Chronic Heart Failure: The Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) Randomized Clinical Trial

Lead/Presenter: David Bekelman, COIN - Seattle/Denver
All Authors: Bekelman DB (VA Eastern Colorado Health Care System) Hattler B (VA Eastern Colorado Health Care System) Fairclough DL (University of Colorado) Allen LA (University of Colorado) McBryde CF (VA Eastern Colorado Health Care System) Havranek EP (University of Colorado) Turvey C (University of Iowa) Meek PM (University of Colorado)

Objectives:
Many patients with chronic heart failure suffer from poor health status (heavy symptom burden, reduced functional status and quality of life). Palliative care provided by specialists shows promise in improving health status in heart failure, yet there are few palliative care specialists, and care should be integrated into the outpatient setting. This study determined whether a palliative and psychosocial collaborative care intervention improved heart failure-specific health status, depression, and bothersome symptoms in outpatients with heart failure.

Methods:
This study was a single-blind, randomized clinical trial conducted at VA, academic, and urban safety net health systems in Colorado. Outpatients with symptomatic heart failure and poor health status were randomized between August, 2012 and April, 2015 to receive the CASA intervention or usual care. The CASA intervention included palliative and psychosocial collaborative care provided by a nurse and social worker, respectively, who worked with patients' primary care providers and were supervised by a study primary care provider, cardiologist, and palliative care physician. The primary outcome was patient-reported heart failure-specific health status, measured by difference in change scores on the Kansas City Cardiomyopathy Questionnaire (range, 0-100), at 6 months. Secondary outcomes included depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder Questionnaire-7) overall symptom distress (General Symptom Distress Scale), specific symptoms (pain, fatigue, shortness of breath), number of hospitalizations, and mortality.

Results:
314 patients were randomized (157 intervention, 157 control). Participants were generally male (77%) and white (63%), and the mean age was 65.5 years. 57% had reduced ejection fraction. At 6 months, mean KCCQ score improved 5.5 points in the intervention arm and 2.9 points in the control arm (difference, 2.7; 95% CI -1.3, 6.6; p = 0.19). Among secondary outcomes, depressive symptoms and fatigue improved at 6 months with CASA (effect sizes of -0.29 and -0.30, respectively, p = 0.02 for both). There were no changes in overall symptom distress, pain, shortness of breath, or number of hospitalizations. Mortality at 12 months was similar in both arms (CASA, 10/157; usual care, 13/157; p = 0.52).

Implications:
This multisite randomized trial of the CASA intervention did not demonstrate improved heart failure-specific health status. Depression and fatigue, both difficult symptoms to treat in heart failure, improved.

Impacts:
The CASA trial was the first clinical trial of a palliative and psychosocial collaborative care intervention to improve health status in heart failure, a common cause of disability among veterans. Further research is needed to implement scalable models of outpatient palliative care.