Screening and Initiating Supportive Care in Patients With Heart Failure

Abstract

Background: Patients with heart failure (HF) experience a major symptom burden and an overall reduction of quality of life. However, supportive care (SC) remains an under-utilized resource for these patients. Among the many existing barriers to integrating SC into routine care, identifying patients with SC needs remains challenging. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is an important predictor of SC needs in patients with HF. Methods and Results: We used the shortened version KCCQ-12 as a screening tool for SC need in our ambulatory HF patient population using a KCCQ-12 summary score of <29 as the cut-off. Of the 456 patients who completed the KCCQ-12, 41 (9%) were predicted to have SC needs. Demographics, medical history, biochemical parameters, echocardiographic assessment and medical treatment were similar between the two groups of patients. However, patients with KCCQ-12 <29 were more symptomatic based on both New York Heart Association (NYHA) classification and American Heart Association (AHA) staging with a higher prevalence of depression. We established a multidisciplinary SC clinic and the profile and outcomes of patients with SC needs that were referred and followed at our SC clinic were also evaluated. Twenty-three patients were referred to our SC clinic: 2 died before being seen, 1 refused SC and 20 received SC. Of these 20 patients, 11 died and 9 are currently being followed. Median survival after starting the SC clinic is 3 months. In the original SC cohort of 23, 17 patients had available KCCQ-12 summary scores. However, only 6 out of 17 (35%) had KCCQ-12 scores <29, indicating the need for additional assessment tools in this patient population. Conclusions: The magnitude of unmet supportive care needs in patients with HF is significant. While the KCCQ-12 questionnaire is a useful tool to identify patients with SC, serial clinical evaluation, establishment of a SC clinic and prompt referral are essential for patients needing supportive care.

Keywords: KCCQ; heart failure; palliative care; quality of life; supportive care.

Figure 1

KCCQ-12 response distribution at baseline. Symptom burden, physical and social limitations, as well as quality of life impairment were reported in reference to the preceding 2 weeks before consultation. Colors categorize responses in terms of how limited patients were in the listed activities, with darker shades representing extreme limitation and lighter shades representing minimal to no limitation N = 456.

Figure 2

(A) Distribution of patients with HF requiring SC, grouped by KCCQ-12 summary score. Using a KCCQ-12 summary score cut-off of <29, 9% of patients with HF require SC N = 456. (B) Median domain scores in patients with and without SC needs. Median scores across the 4 domains as assessed by the KCCQ-12 are shown, with patients grouped according to the chosen KCCQ-12 cut-off score of <29 N = 456.

Figure 3

(A) Supportive care model for patients with HF. Schematic model of SC integrated into routine care for patients with HF at the Heart Function Clinic. HF, heart failure; SC, supportive care; HCPs, health care providers; NP, nurse practitioner; RN, registered nurse; PT, physical therapist; RT, respiratory therapist; OT, occupational therapist; EMS, emergency medical services. (B) Overview of heart failure patients referred to SCC. Twenty-three patients were initially referred to our SC clinic (SCC). Shown are the various outcomes we observed for these patients.