Advance directive screening among veterans with incident heart failure: Comparisons among people aging with and without HIV

Abstract

Background: Heart failure (HF) is common among people aging with HIV (PWH) and without HIV (PWoH). Despite the poor prognosis for HF, advance directives (AD) completion is low but has not been compared among PWH and PWoH.

Objectives: Determine the prevalence and predictors of AD screening among PWH and PWoH with incident HF.

Methods: We included Veterans with an incident HF diagnosis code from 2013-2018 in the Veterans Aging Cohort Study (VACS) without prior AD screening. Health records were reviewed for AD screening note titles within -30 days to 1-year post-HF diagnosis. Analyses were stratified by HIV status. Trends in annual AD screening were evaluated with the Cochran-Mantel-Haenszel test. The associations of AD screening with demographics, disease severity (Charlson Comorbidity Index, VACS 2.0 Index), and healthcare encounters (cardiology, palliative care, hospitalization) were evaluated with Cox proportional hazards regression.

Results: HF was diagnosed in 4516 Veterans (28.2% PWH, 71.8% PWoH). Annual AD screening rates increased in both groups (P_trend<0.0001) and aggregate rates were higher among PWH than PWoH (53.5% vs. 48.2%, p=.001). In both groups, the likelihood of AD screening increased with greater disease severity, palliative care contact, and hospitalization (HR range=1.04-3.32, all p≤.02) but not with cardiology contact (p≥.53).

Conclusions: AD screening rates after incident HF remain suboptimal but increased over time and were higher in PWH. Future quality improvement and implementation efforts should aim for universal AD screening with incident HF diagnosis, initiated by providers skilled in discussing AD, including in the cardiology subspecialty setting.

Keywords: Advance care planning; Advance directive; End-of-life; HIV; Heart failure; Veteran.

Figure 1.

AD Screening in the 1-Year After Incident HF in Veterans With and Without HIV Infection. PWH=People aging with HIV, PWoH=People aging without HIV. Values are the percentages within each group (PWH, PWoH) and bars represent 95% confidence intervals. Excludes Veterans with AD Screening >30 days prior to HF diagnosis. Preference for color: online only.