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2023 HSR&D/QUERI National Conference Abstract

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1001 — Effect of a Collaborative Palliative Care Intervention on Quality of Life in Veterans with Symptomatic Lung and Heart Diseases: The ADAPT RCT

Lead/Presenter: David Bekelman
All Authors: Bekelman DB (Denver/Seattle COIN, Department of Medicine, VA Eastern Colorado Health Care System and the University of Colorado), Baron A (Denver/Seattle COIN, University of Colorado) Parsons EC (Pulmonary and Critical Care, VA Puget Sound) Welsh CH (Pulmonary and Critical Care, VA Eastern Colorado) Paden G (Primary Care and Palliative Care, VA Puget Sound) McBryde C (Primary Care, VA Eastern Colorado) Cheng A (Cardiology, VA Puget Sound) Au DH (Denver/Seattle COIN, Pulmonary and Critical Care, VA Puget Sound)

Objectives:
Veterans with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. While the National Academy of Medicine, WHO, and professional societies call for outpatient palliative care for these illnesses, access to outpatient palliative care specialists is limited to non-existent. New, scalable models of palliative care delivery are needed. This study determined the effect of a phone-based collaborative palliative care intervention on quality of life in outpatients with COPD, HF, or ILD compared to usual care.

Methods:
We conducted a single-blind, 2-arm, multisite randomized clinical trial within 2 VA health care systems. We included outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life. The intervention included symptom care provided by a nurse and psychosocial care provided by a social worker. The nurse and social worker met weekly with a study primary care and palliative care physician, pulmonologist, and cardiologist. Each component of the intervention was structured, templated, and operationalized in a treatment manual. The primary outcome was difference in change in quality of life from baseline to 6 months between intervention and usual care (FACT-G score, range, 0-100, higher score better, clinically meaningful change ?4 points). Secondary quality of life outcomes at 6 months included disease-specific health status (CCQ [COPD], KCCQ-12 [HF]), depression (PHQ-8), and anxiety (GAD-7). Analysis used the intent-to-treat approach and mixed models.

Results:
A total of 306 Veterans were randomized (154 intervention, 152 usual care). Participants were generally male (90.2%), white (80.1%), with a mean age of 68.9 (SD 7.7) years; 57.8% had COPD, 21.9% HF, 16% both COPD/HF, 4.2% ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% at 6 months for both intervention and usual care groups. In the intervention arm, 112/154 (73%) patients completed the planned intervention. At 6 months, mean FACT-G score improved 6.0 points in the intervention arm and 1.4 points in the usual care arm (difference, 4.6; 95% CI 1.8, 7.4; p = 0.001; standardized effect size (ES), 0.41). This effect was observed at all time points (4-month difference, 3.5; 95% CI, 1.4, 7.4; ES, 0.30, p = 0.02; 12-month difference, 4.9, 95% CI, 1.4, 13.6; ES, 0.36; p = 0.007). ADAPT also improved COPD health status (ES 0.44, p = 0.04), HF health status (ES 0.41, p = 0.01), depression (ES -.50, p < 0.00) and anxiety (ES -0.51, p < 0.00) at 6 months.

Implications:
A telephonic collaborative palliative care intervention demonstrated early, persistent, and clinically meaningful improvements in quality of life for symptomatic high-risk Veterans with lung and heart diseases who reported poor quality of life.

Impacts:
This virtual care model leveraged a team of nurses, social workers, and physicians across two large VA health systems to increase the reach of palliative care to common, serious non-cancer illnesses. Future studies should evaluate cost and implementation of this care model which is well-suited to improve specialist access for Veterans in low-resource settings.