Promoting Palliative Care for People with Heart Failure: The P3HF Pilot Study

Project Summary Heart failure is a leading cause of morbidity and mortality, projected to affect more than eight million Americans by 2030. Frequent symptoms, hospitalizations, and hospital readmissions are common among this population, causing significant suffering, particularly near the end of life. Conversations about prognosis, the benefits and harms of invasive treatments, and patient care goals and preferences are essential to promote goal- concordant care among this population. Yet, these conversations occur infrequently. To address these critical needs, the American Heart Association, the American College of Cardiology, and the Heart Failure Society of America recommend palliative care as a Class I (strong) recommendation “for all patients with heart failure to improve quality of life and relieve suffering.” However, fewer than 20% of this population receive Specialist Palliative Care. Patient prognosis is a key criterion for referral to palliative care among this population. Our team developed and validated an automated electronic health record-based 1-year mortality risk model for people hospitalized with heart failure and embedded the model into an interruptive alert to facilitate clinician decision-making. While the alert was highly accurate, acceptable, and feasible among clinicians, it did not result in a significant increase in referrals to Specialist Palliative Care in a subsequent clinical trial. Interruptive alerts deliver the right information but often at the wrong time, resulting in clinician overrides and task abandonment. Non-interruptive clinical decision support (CDS), such as targeted modal alerts and passive designs, provides innovative alternatives to interruptive alerts. However, their effectiveness hinges on careful user-centered design and the development of strategies for implementation. Thus, our overall objective is to design and pilot test the Promoting Palliative Care for People with Heart Failure (P3HF) CDS, a tool that incorporates our 1-year mortality alert with evidence-based CDS design, and critically, pairs the CDS with strategies for implementation. To accomplish our objectives, we will design the P3HF CDS and develop an accompanying implementation package using a theory-informed process involving interviews, iterative design, and focus-group-led evaluation with healthcare provider stakeholders (Aim 1). Next, we will conduct a randomized real-world pilot trial across two hospitals to evaluate the usability, acceptability, appropriateness, and feasibility of the P3HF CDS and implementation package. We will also examine the intervention's preliminary efficacy on clinician behavior change (i.e., referral to Specialist Palliative Care, primary outcome) and patient outcomes (i.e., Advance Care Plan documentation, hospice enrollment, hospital length of stay, 30- day hospital readmission, exploratory secondary outcomes; Aim 2). This study will provide essential data necessary and sufficient to inform a subsequent multi-site hybrid efficacy-effectiveness clinical trial of the P3HF CDS and implementation package. If successful, this project will result in an evidence-based, generalizable intervention that could greatly improve care delivery and quality of life for people with heart failure.