Factors influencing palliative care referral for hospitalised patients with heart failure: an exploratory, randomised, multi-institutional survey of hospitalists and cardiologists

Abstract

ObjectiveTo identify factors influencing cardiologists’ and hospitalists’ decisions regarding palliative care referral among hospitalised patients with advanced heart failure.DesignAn exploratory, randomised vignette-based survey.SettingCardiology and hospitalist divisions at three Michigan State institutions and the Society of Hospital Medicine’s Michigan Chapter.Participants145 hospitalists and 64 cardiologists.Outcome measuresPrimary outcomes included participants’ reports of their likelihood of referring a standardised patient with an acute heart failure exacerbation with multiple prior hospital admissions and acute renal failure to palliative care (scale of 0%–100%) after the initial stem and after being cued with three randomised vignette modifiers, including the presence versus the absence of continuity with an outpatient cardiologist; the presence versus the absence of documented advance care planning; and the patient voicing that he is accepting of his severe illness versus wanting everything done. Adjusted generalised linear models and predictive margins were used to evaluate the impact of each randomised modifier on referral decisions. An interaction term evaluated the effect of provider specialty on outcomes. Secondary outcomes included participants’ reports of their general practices around palliative care delivery to hospitalised patients with heart failure.ResultsResponse rate was 31.3%. Predictive margins from generalised linear models demonstrated a statistically significantly higher likelihood of referral to inpatient palliative care if the patient lacked an outpatient cardiologist (mean difference: 6.3% (95% CI 1.8% to 10.8%)); had prior advance care planning documentation (mean difference: 9.7% (95% CI 4.4% to 15.0%)); and was accepting of illness severity (mean difference: 29.6% (95% CI 24.8% to 34.4%)). No interaction effect was noted based on provider specialty. Most hospitalists and cardiologists were unaware of palliative care guidelines for patients with heart failure (74.3% vs 70.3%, p=0.71).ConclusionsA number of patient and provider factors influence palliative care referral decisions in hospitalised patients with advanced heart failure.

Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study

“…The reduction in daily medical costs confirmed that cost reduction was not solely due to shorter LOS. However, there has been great variability in the practice patterns of hospitalists worldwide [19,20]. In addition, the learning curve, experience, and available support of hospitalist teams may influence the process and utilization of aggressive intensive care [21].…”

Predictors of referral behaviour and intention amongst physicians in a medical consortium based on the theory of planned behaviour: a cross-sectional study in China

“…Reliability was assessed using Cronbach’s α (>0.6) ( 44 ). Convergent validity was assessed using the average variance extracted (AVE > 0.36) and composite reliability (CR > 0.6) for all constructs ( 20 ). Discriminant validity was tested using the Fornell–Larcker criterion.…”

A Systematic Review of the Development and Implementation of Needs-Based Palliative Care Tools in Heart Failure and Chronic Respiratory Disease

“…A range of patient-, provider- and system- related factors contribute to non-referrals, late or crisis referrals to palliative care for patients with chronic HF and chronic respiratory disease. Patients and families have identified denial, misperception about the potential benefits and purpose of palliative care, and negative previous experiences with services ( 20 , 21 ). While some providers report feeling comfortable providing a palliative approach ( 22 ), for others there is uncertainty about the role of palliative care and when this approach should be introduced ( 23 , 24 ).…”

“…While some providers report feeling comfortable providing a palliative approach ( 22 ), for others there is uncertainty about the role of palliative care and when this approach should be introduced ( 23 , 24 ). Health care providers' poor recognition of their patient's palliative care needs can be impacted by time constraints, a lack of education or training, and awareness or availability of standardized tools and referral pathways ( 20 , 22 – 25 ). Some health care providers perceive palliative care is not as useful for non-malignant conditions or that SPC services prioritize patients with cancer ( 26 ).…”

“…Some health care providers perceive palliative care is not as useful for non-malignant conditions or that SPC services prioritize patients with cancer ( 26 ). Limited availability of SPC services and workforce shortages also limit timely referrals ( 20 , 23 , 25 , 27 ). Poor integration of palliative care and cardiology and respiratory services has been reported ( 28 ).…”