Warraich, H. J., & Meier, D. E. (2019). Serious-Illness Care 2.0 — Meeting the Needs of Patients with Heart Failure. New England Journal of Medicine, 380(26), 2492–2494. https://doi.org/10.1056/NEJMp1900584
This week’s paper of the week is brought to you by Dr Tim Wilson, Managing Director
Heart failure is the most common cause of hospitalizations among elderly Americans, and despite much medical and scientific progress, it remains a source of substantial suffering, expense, and caregiver burden. Palliative care can improve quality of life, symptoms, and functioning for people with serious illnesses, and a recent observational study in patients with heart failure showed that enrollment in home hospice was associated with fewer emergency department (ED) visits and intensive care unit stays, shorter stays in the hospital, and longer survival. Yet palliative care and hospice care remain grossly underused for heart failure.
3V bottom line (e.g. our overall conclusion, probably a longer version of the title):
At the end of life, we would hope that health and social care systems could focus their efforts to provide best value, but this paper shows that in conditions like heart failure, the opposite is often true. Health systems are delivering low population and low personal value; so much more could be done without extra resources, for this most important group of people- those who are dying.
3VH – Implications for value:
Atul Gawande in his Reith lecture talk, the Problem of Hubris, and his book, ‘Being Mortal’, outlined how it seemed that health and social care systems seemed to have lost their way when to comes to what matters. He outlines a number of cases and studies that outline how focussing attention on what really matters to individuals that are dying would provide greater value.
This paper outlines the problems with heart failure. It describes how people dying of heart failure:
- Are often identified late;
- Share, with their doctor, a degree of over-optimism about the benefits of treatment, and under estimation of harm;
- Are subject to almost inevitable and inexorable trajectory of repeated exacerbations, associated with and admission and fail to fully recover- and yet this is generally ignored
- Are subject to a mismatch in expectations with cardiologists who are pursuing longevity believing that to be the main priority, whereas individuals dying of heart failure often seek other outcomes.
The causes are also described, albeit from a US perspective, although our experience is that these apply equally in other universal health systems like the NHS, including
- Failure to coordinate care;
- Lack of training and awareness amongst cardiologists
- Poor alignment delivery structures and payment mechanisms.
At 3V we would not disagree with these causes, but would emphasise them differently, and feel there are some important omissions:
- Culture; we need a culture of stewardship, so that the resources for people who are dying are used most wisely. A governance system that enables this culture is also important.
- Population: Define the population who will benefit from higher value end of life care. Be clear about the population groups you are addressing- in the case of this paper, it would include people with severe heart failure. Then define how the population is constituted (e.g. on a GP registered list, living in a particular area).
- Value framework: Be clear about the outcomes that matter to that population. Agree a set of outcomes that matter, objectives that should deliver those outcomes and criteria. Agree the resources available to deliver those outcomes and objectives.
- Value- driven network. Create a network of people drawing from key stakeholder groups (including people who are dying and their carers) who will have authority for the making optimal use of the resources for people at the end of life and be held accountable for delivering the best possible outcomes.
- Personalise care. Ensure that care is personalised so that the preferences of each individual in the last year of life, their family and carers is elicited, recorded and as far as is practicable, honoured.