Physicians are less likely to recommend hospice and palliative care to patients suffering from cardiac conditions, such as congestive heart failure, compared to patients who have other conditions such as cancer, a recent study indicates.

Numerous hospices provide palliative care, and an increasing number are diversifying their service. Education of clinicians treating cardiovascular patients can help increase referrals for patients who need this type of care, according to the study’s authors.

In the study, data analysis from records of 1,801 cardiovascular patients receiving care between 2015 and 2017 from 16 health care organizations, showed that palliative care referrals from cardiologists dropped to 10.5% from 16.5%.

Referrals of cardiovascular patients by general medicine physicians rose to 52.9% in 2017 from 43.2% in 2015; nevertheless, researchers found that referrals for heart patients lagged considerably behind those for patients with other illnesses.

Though this study focused on palliative care, the trend of lower referrals for cardiac patients applies to hospice as well, study authors said.

“There definitely is variation in referrals to both palliative care and hospice care by diagnosis,” said Haider Warraich, MD, cardiologist at the Duke University School of Medicine and lead author of the study. “Patients with cancer form the majority of those who are referred to both hospice and palliative care, while patients with cardiovascular disease — which is still the leading cause of death in the United States — are underrepresented.”

Numerous factors contribute to underutilization of palliative care and hospice by cardiovascular patients. One significant consideration according to Warraich is organizational culture among the health care settings that make referrals. Whereas oncologists generally are aware of hospice and palliative care and see them as routine parts of oncology treatment, that is far less common among cardiologists and other clinicians that treat heart disease.

The common misconception that palliative care, like hospice, is currently only provided at the end of life also plays a role. Many clinicians and patients hold the incorrect belief that a referral to palliative care means cessation of curative treatment.

“The other major barrier is prognostic uncertainty. Estimating a prognosis in patients with cardiovascular disease is very difficult,” Warraich said. “Yet, these patients tend to have a high symptom burden and would benefit from palliative care or hospice. But because this is not recognized by either the patients or the physicians, it leads to far fewer palliative care referrals.”

Prognostic uncertainty is a key factor largely due to the six-month requirement for a hospice referral. When physicians and patients believe that palliative care can only happen within six months of the end of life, the unpredictability of those conditions can inhibit referrals.

Among patients who do receive a referral, it often comes too late. The median survival of patients with heart failure who have been referred to hospice is 11 days, Warraich told Hospice News.

Redesigning the payment system to base hospice referrals on patient needs rather than a six-month prognosis can also make a difference, Warraich indicated. Others in the industry have made similar calls, including National Hospice and Palliative Care Organization President Edo Banach in an interview with Hospice News.

“Moving to a needs-based referral pattern for patients would be more beneficial,” Warraich said. “The six-month requirement limits clinicians in referring patients to hospice. That is something that needs to be tested and worked out: Designing models of care to allow increased flexibility in payment for those services.”

A single solution will not solve this multifaceted problem, but any effort to increase hospice and palliative care utilization among heart patients will certainly include education programs for patients and referrers.

“We need to educate patients as well as clinicians about the increasing need for more concurrent palliative care in patients with cardiovascular disease, meaning we need to change the notion that you can only receive either conventional therapy or palliative care. They are not mutually exclusive,” Warraich told Hospice News. “We need models of palliative and hospice care that are much more designed for patients who are suffering from cardiovascular disease that meets their specific needs.”

Some hospices are already at work developing such cardiac-specific hospice and palliative care programs. Crossroads Hospice and Palliative Care’s Heartlink program is designed specifically for heart failure patients and their caregivers. The hospice also operates disease-specific hospice and palliative care programs for patients with dementia and renal diseases.
Hospice and palliative care provider CareDimensions offers a cardiovascular patient-specific program called Heart-to-Heart.

“I always think that the way to take care of these patients is for cardiologists and palliative care and hospice clinicians to work together, especially for those patients approaching the end of life or those who have a serious illness,” Warraich said. “We have a lot to learn from on another, and this is an area where collaboration is really needed.”