Variation in Uptake of Specialist Palliative Care Among People with Advanced Heart Failure Across VA Medical Centers

Outcomes 1. Participants will describe variation in SPC uptake and identify modifiable factors of specialist palliative care delivery associated with the uptake of SPC among people with advanced heart failure within the Department of Veterans Affairs.2. Participants will assess how study findings can inform future research and implementation efforts to expand access to palliative care for people with advanced heart failure. Key Message The Department of Veterans Affairs mandates that all people with serious illness have access to specialist palliative care. However, among people with advanced heart failure, we found substantial variation in the uptake of specialist palliative care. Specific delivery characteristics were associated with high facility uptake across the nationwide system. Introduction The Department of Veterans Affairs (VA) mandates that all people with serious illness have access to specialist palliative care (SPC). Yet, rates of SPC consultation in the VA are 45% lower among people with advanced heart failure (aHF) relative to people with cancer. It is unknown whether the low rates of SPC uptake are consistent across VA Medical Centers (VAMCs), and the extent to which rates reflect differences in structures and processes of SPC delivery. Objectives We examined medical center variation in SPC uptake and identified factors associated with variation in uptake among people with aHF. Methods We conducted a retrospective cohort study of 21,653 people with aHF who received health care in 83 VAMCs. We defined aHF with ICD-9/10 codes and hospitalizations. We used random intercept multilevel logistic regression to derive predicted probabilities of SPC uptake for each VAMC adjusting for demographic and clinical characteristics. Using multiple regression, we examined VAMC-level SPC delivery characteristics associated with predicted SPC uptake including SPC team staffing (full-time equivalents (FTE) and the use of outpatient SPC. Results Of 21,654 people with aHF (Mean age = 72.9+ 10.9 years) 97.9% were male, 61.6% White, and 32.2% were Black. The predicted uptake of SPC varied substantially across VAMCs from 9-57% [mean: 28% (95% Confidence Interval: 25-30%). VAMC SPC teams with greater total FTE (≥4 vs. < 4 FTE) and a higher proportion of outpatient SPC consults (≥9% vs. < 9%), had 4.9% and 9% higher predicted rates of SPC uptake respectively. Conclusion Rates of SPC uptake among people with aHF vary markedly across VAMCs. Outpatient SPC delivery resulted in the highest VAMC rates of SPC uptake among this population. Additional research is needed to better understand the drivers of high and low uptake across VAMCs for people with aHF and identify and disseminate best practices in SPC delivery. Keywords Models of Palliative Care Delivery / Scientific Research