Veterans with chronic heart failure (HF) experience a highly morbid and life-limiting illness while suffering from substantial physical and psychosocial burdens. Despite guideline-based HF management, many patients continue to report a high prevalence of both the typical HF symptoms of breathlessness and fatigue as well as depression, anxiety, and pain which reduce quality of life but are not routinely managed in HF care. Gaps exist in the health care provided to Veterans with HF because interventions have not specifically targeted patients' typical HF and other symptoms, comorbid depression, and adjustment to a limited and uncertain future. Palliative care, defined as care devoted to improving quality of life in patients with life-threatening illness, is best provided concurrently from time of diagnosis along with life-prolonging treatment. Its focus on symptom alleviation, patient function, and quality of life is particularly relevant to patients with HF because it is difficult to prognosticate when patients are at the end of life. This study examines an evidence-based palliative care intervention that targets symptom burden, adjustment to illness, and quality of life in patients with HF.
The objectives of this study were to: (1) implement an evidence- and guideline-based palliative symptom management and psychosocial care intervention to improve symptoms and quality of life for Veterans with HF and poor health status at the Denver VA Medical Center; (2) conduct a formative evaluation by examining (a) key stakeholder concerns with and barriers to implementation of the intervention, and (b) intervention provider experience with and adherence to the intervention; and (3) conduct a summative evaluation by measuring health status, depression, and symptom burden before and 3 months after enrollment in the intervention.
This project was a pilot implementation study of an evidence-based palliative care intervention, Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) to improve symptoms and quality of life in veterans with HF. We used a prospective mixed-methods pilot clinical trial. The intervention included nurse phone visits with three structured symptom guidelines to address (1) breathlessness or fatigue, (2) pain, or (3) depression; a social worker who provided structured phone counseling targeting adjustment to illness and depression if present; and brief weekly team meetings with a palliative care specialist, cardiologist and primary care physician who made medical recommendations to improve symptoms. A convenience sample of patients with chronic heart failure was recruited from outpatient cardiology clinics and inpatient medical wards of the Denver VAMC. The study tracked intervention process and quality of care; baseline and three month self-report outcome measures; and conducted a post-study semi-structured participant interview for feedback on the helpfulness of the intervention and recommendations for changes.
To identify other intervention implementation facilitators and barriers, we interviewed nurses, physicians in multiple specialties, service chiefs, the hospital chief of staff, and two national leaders from VACO (total n=17). A semi-structured interview guide was used. Interviews were audiotaped, detailed notes were taken. The analysis used a general inductive approach, guided by the CFIR model.
Seventeen male participants enrolled in the study with New York Heart Association Class II-IV heart failure and their median age was 63. One subject withdrew from the study early and there was <5% missing data. The primary symptoms targeted included fatigue or breathlessness (single treatment guideline for both symptoms, 47%) or pain (53%), although participants found other symptoms to be "most bothersome" such as cough (12%) and numbness/tingling in hands/feet (12%). Ninety to 100% of medical recommendations (medication changes, n=23; tests, n=11; or consults, n=2) were completed except for physical therapy visits (60% completed, n=5 referrals). Participants felt that the nursing component was a "good source of information" about self-management and included the right number of and timing of phone visits. They recommended reducing the nurse phone symptom survey length. Most enjoyed speaking to the social worker. Some felt the content of the psychosocial component did not fit with their situation "because I'm not depressed."
The CASA intervention was feasible based on participant cohort retention and acceptability of the intervention. Several intervention changes were made based on participant feedback, including shortening nurse symptom assessments, addressing symptoms besides the four target symptoms, modifying the psychosocial language to make it less depression-focused, and increasing the flexibility around which psychosocial modules are provided.
Providers and leaders were generally very enthusiastic about implementing the CASA program. Preliminary analysis suggested key implementation barriers are funding, the need to demonstrate cost-effectiveness, and whether CASA should be implemented through PACT or in cardiology specialty care.
The CASA heart failure palliative care intervention is feasible, perceived as helpful, and compliments current VA HF disease management by focusing on symptom alleviation, adjustment to illness, and quality of life, components of palliative care that are best provided concurrently with life-prolonging treatments. The CASA intervention can thus fill a gap in the care of veterans with HF.
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