By Heather Veeder, MD, Regional Medical Director, VITAS Healthcare
Chronic heart failure is a major cause of morbidity and mortality worldwide: Among people over 65, it is the leading cause of hospitalization, and in many countries, it is the leading disease in terms of healthcare costs. Despite advances in care, heart failure continues to remain highly prevalent and carry a poor prognosis—after diagnosis, around 50% of heart failure patients die within 5 years.1
Hospitalizations and Readmissions: Challenges Facing Heart Failure Patients
The morbidity and mortality of heart failure become increasingly high near end of life: Symptoms worsen, and unpredictable exacerbations of breathlessness increase in frequency and severity. These exacerbations become more difficult to manage, resulting in frequent hospitalizations and subsequent readmissions.
In chronic heart failure, hospitalizations are very common and peak toward end of life. In fact, 80% of heart failure patients are hospitalized in the last 6 months of life.
While hospital admissions can support frequent and severe exacerbations that cannot be adequately managed in the community, frequent hospitalizations and readmissions come with their own costs and risks as well. Frequent admissions disrupt continuity of care, intensify resource use, increase the use of burdensome treatments, subject patients to potentially unnecessary interventions, and expose patients to increased risk of hospital-acquired adverse events such as infection.1
In addition, frequent hospitalizations and readmissions increase the likelihood of a patient dying in hospital against their wishes; most patients with terminal heart disease prefer to be cared for and to die at home or in an inpatient hospice.1
An Unmet Need
Hospice services remain underutilized among heart failure patients, a population that could immensely benefit from these services.
A systematic review of studies examining all-cause or heart failure hospitalizations in adult patients with advanced chronic heart failure conducted by Zehnder et al.1 showed that:
- Chronic heart failure patients often suffer from palliative care-related problems with substantially higher prevalence of needs in advanced NYHA stages.
- There is still a great disparity of specialist palliative care provision in heart failure compared to cancer patients despite increasing recognition of positive effects on patient-reported outcomes.
- Patients with advanced heart failure are significantly less likely to have clinicians discussing hospice with them, experience more frequent emergency department visits and hospitalizations after hospice enrollment than cancer patients, and are admitted to hospice care closer to death.
- A variety of barriers to specialist palliative care referrals of heart failure patients have been documented, including misconceptions and confusion around terminology, difficulties of accurate prognostication, and uncertainties about referral triggers.
Looking at the needs, disparities, and challenges faced by heart failure patients, it is clear that there is need in this population for the services that timely hospice care can provide.
Hospice Care Reduces Unnecessary Hospital Readmissions
Zehnder et al.'s systematic review1 identifies strong evidence that access to hospice and specialist palliative care is associated with fewer hospitalizations in advanced chronic heart failure.
Having access to these specialist interventions was associated with a lower likelihood of both all-cause hospitalizations and heart failure hospitalizations in patients with advanced chronic heart failure.
The study concluded that hospice and specialist palliative services should be involved in the care of patients with advanced chronic heart failure to avoid unnecessary hospital admissions at the end of life.
Assessing Hospice Eligibility for Heart Failure Patients
Patients with NYHA class III or IV heart disease (as defined below) are likely eligible for hospice services if they:
- Exhibit symptoms at rest or with minimal exertion
- Exhibit worsening symptoms when undertaking physical activity
- Are unable to carry out physical activity without symptoms
- Are symptomatic despite optimal or maximal treatment and are not pursuing surgical options
- Experience recurrent heart failure exacerbations
- Experience frequent emergency department visits or hospitalizations
- Have significant comorbidities, including diabetes, hypertension, or another life-limiting illness, and/or
- Are increasingly dependent in self-care
Ending the Hospital Readmission Cycle
Heart failure is a complex chronic condition, and as patients with advanced heart failure approach end of life, exacerbations and the accompanying hospitalizations and subsequent readmissions become increasingly frequent. It is at this time that the services hospice can provide become invaluable. Studies have shown that access to hospice services is strongly associated with significantly lower rates of all-cause and heart failure-related hospitalizations in patients with advanced heart failure.
Involving hospice in the care of a patient with advanced heart failure can end the hospital readmission cycle, preserve continuity of care, promote effective resource utilization, reduce the risk of unnecessary interventions, and reduce the burden of treatment. In addition to managing a patient's symptoms, the members of the hospice interdisciplinary team work together to address the patient's social, emotional, and spiritual needs as well.
If your patient with advanced heart failure is hospice-eligible and chooses hospice care, partner with a hospice provider that has a proven record of delivering the highest-quality clinical, spiritual, and emotional services.
1Zehnder AR, Pedrosa Carrasco AJ, Etkind SN. Factors associated with hospitalisations of patients with chronic heart failure approaching the end of life: A systematic review. Palliative Medicine. 2022;36(10):1452-1468. doi:10.1177/02692163221123422