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Table.  
Symptom Severity and Lack of Improvement
Symptom Severity and Lack of Improvement
1.
Goodlin  SJ.  Palliative care in congestive heart failure. J Am Coll Cardiol. 2009;54(5):386-396.
PubMedArticle
2.
Retrum  JH, Boggs  J, Hersh  A,  et al.  Patient-identified factors related to heart failure readmissions. Circ Cardiovasc Qual Outcomes. 2013;6(2):171-177.
PubMedArticle
3.
Light-McGroary  K, Goodlin  SJ.  The challenges of understanding and managing pain in the heart failure patient. Curr Opin Support Palliat Care. 2013;7(1):14-20.
PubMedArticle
4.
Hunt  SA, Abraham  WT, Chin  MH,  et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society.  ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112(12):e154-e235.
PubMedArticle
5.
Liu  L.  Changes in cardiovascular hospitalization and comorbidity of heart failure in the United States: findings from the National Hospital Discharge Surveys 1980-2006. Int J Cardiol. 2011;149(1):39-45.
PubMedArticle
Research Letter
October 2015

Symptom Burden Among Patients Who Were Hospitalized for Heart Failure

Author Affiliations
  • 1Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 2Yale School of Nursing, New Haven, Connecticut
  • 3Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
  • 4Geriatrics Research Education and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, New York
  • 5Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
JAMA Intern Med. 2015;175(10):1713-1715. doi:10.1001/jamainternmed.2015.3871

Heart failure (HF) is a leading cause of 30-day readmission.1 Missing from our understanding of decompensated HF is the range and natural history of the symptoms that affect patients. Residual symptoms are known to be a powerful driver of health care use after hospitalization for HF.2 Intensive symptom management, including palliative care, may represent a promising approach to improving patient outcomes after hospitalization for HF. Our objectives were to evaluate the spectrum of symptoms experienced by patients hospitalized for HF, the improvement in symptoms after discharge, and patients’ perceptions of palliative care.

Methods

This was a prospective study of patients who were hospitalized for HF at Yale–New Haven Hospital. The study was conducted from August 21, 2013, through December 31, 2014. Institutional review board approval was given by Yale–New Haven Hospital and written patient consent was obtained. Patients were enrolled within 2 days of hospital admission and queried about symptoms using the Edmonton Symptom Assessment Scale during hospitalization and a follow-up telephone interview 1 week after discharge. This scale ranges from 0 to 10, with higher scores denoting greater severity. Severity ratings were compared between the in-hospital and postdischarge assessments to assess improvement in symptoms. Patients were also queried about existing knowledge of palliative care and interest in receiving palliative care services while hospitalized.

Results

Ninety-one patients were enrolled. The mean (SD) time for the baseline interview was 2.5 (1.6) days after hospital admission. The mean (SD) time for the follow-up interview was 9.9 (4.3) days after hospital discharge. The patients’ mean (SD) age was 71.5 (12.6) years, 47 (52%) were female, and 68 (75%) had an ejection fraction of less than 50%.

The Table shows the patients’ symptom severity at baseline and follow-up as well as the percentage of patients who reported no improvement. Severe symptoms during hospitalization included symptoms that are traditionally associated with decompensated HF (decreased well-being, fatigue, and dyspnea) as well as those that are not (anxiety and pain). A lack of symptom improvement shortly after hospital discharge was common. A total of 49 patients (58%) reported no improvement in fatigue, 36 (42%) reported no improvement in dyspnea, 35 (41%) reported no improvement in pain, and 35 (41%) reported no improvement in anxiety.

While only 19 patients (22%) reported familiarity with palliative care, after a standardized explanation, 58 (68%) were interested in receiving palliative care services. Of those who were already familiar with palliative care, the perceptions about the types of services provided are shown in the Box.

Box Section Ref ID
Box.

Patient Responses Regarding Their Perceptions of Palliative Care

  • Takes care of very ill patients and make them comfortable.

  • Visiting nurse, home care.

  • Home care for elderly and sick.

  • Pain relief, patient comfort, support for family.

  • The kind to help support people who aren’t feeling well.

  • Helping patients get along and cope with symptoms.

  • Comfort to dying patient and family, relieve family from care.

  • Help with day-to-day activities, not in hospital setting.

  • Keeping people comfortable as they end their lives.

  • Outpatient basic services that help with day-to-day care.

  • Useful for older people at end of life when they need lots of medical care.

  • For cancer patients in extreme pain.

  • For dying patients.

  • The patient whose departure is imminent.

  • Semiholistic approach to care.

  • Comfort care.

  • When someone comes in and helps make decisions.

  • Visiting nurse who gives medications.

  • Hospice care when end is coming.

  • Nurses coming in to help at home.

  • Hospice care right before people die.

  • Team effort towards the patient to provide everything the patient needs.

  • Helps cancer patients.

  • Scientific care combined with nontraditional care.

  • Not hospice care, prehospice care.

Discussion

Our findings suggest that patients who are hospitalized for HF often present with symptoms that are not traditionally associated with HF and that current management approaches may fail to adequately address symptoms. There may be several reasons for this failure. The existence of multiple comorbid medical conditions is common in aging patients with HF, and these comorbidities may contribute to symptoms and complicate management. Physicians who care for patients with HF in the hospital setting may not be prepared to thoroughly assess and treat symptoms such as pain, anxiety, depression, and fatigue.3 Finally, there is pressure on health systems to reduce patients’ lengths of stay. Once patients no longer meet the clinical criteria for hospitalization (eg, hypoxia or hemodynamic instability), there is an impetus for discharge even if troublesome symptoms persist.

The progressive nature of HF, coupled with high mortality rates and poor quality of life, make it suited for the incorporation of palliative care. Given that symptoms frequently drive health care use, early integration of palliative care may reduce readmissions. There have been numerous calls to include palliative care as a component of HF management, but fewer than 10% of patients with HF receive palliative care.4,5 To our knowledge, this is the only study that included a longitudinal assessment of symptom burden during hospitalizations for HF and shortly after discharge. Future studies should evaluate whether palliative care is effective in reducing symptom burden and readmission among patients who are hospitalized for HF.

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Article Information

Corresponding Author: Sarwat I. Chaudhry, MD, Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, Harkness Office Bldg, 367 Cedar St, Room 416, PO Box 208088, New Haven, CT 06520.

Published Online: August 17, 2015. doi:10.1001/jamainternmed.2015.3871.

Author Contributions: Drs Khan and Chaudhry had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Khan, Chaudhry.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Khan, Chaudhry.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Khan, Chaudhry.

Obtained funding: Khan.

Administrative, technical, or material support: Khan, Chaudhry.

Study supervision: Chaudhry.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by a pilot grant from the National Palliative Care Research Center (Drs Chaudhry and Goldstein).

Role of the Funder/Sponsor: The National Palliative Care Research Center had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Goodlin  SJ.  Palliative care in congestive heart failure. J Am Coll Cardiol. 2009;54(5):386-396.
PubMedArticle
2.
Retrum  JH, Boggs  J, Hersh  A,  et al.  Patient-identified factors related to heart failure readmissions. Circ Cardiovasc Qual Outcomes. 2013;6(2):171-177.
PubMedArticle
3.
Light-McGroary  K, Goodlin  SJ.  The challenges of understanding and managing pain in the heart failure patient. Curr Opin Support Palliat Care. 2013;7(1):14-20.
PubMedArticle
4.
Hunt  SA, Abraham  WT, Chin  MH,  et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society.  ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112(12):e154-e235.
PubMedArticle
5.
Liu  L.  Changes in cardiovascular hospitalization and comorbidity of heart failure in the United States: findings from the National Hospital Discharge Surveys 1980-2006. Int J Cardiol. 2011;149(1):39-45.
PubMedArticle
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