Pain Outcomes Among Medical Centers With High vs Low Specialist Palliative Care Reach Among People With Heart Failure

Background: Pain affects more than 60% of people with heart failure (HF), with increasing frequency and severity towards the end of life (EOL). We examined if family-rated pain near EOL was associated with rates of specialist palliative care (SPC) among patients with HF. Methods: We conducted a retrospective cohort study among 1095 decedents with advanced HF (aHF = ≥2 hospitalizations) from 83 Veterans Affairs Medical Centers (VAMCs) between 2018-2020. We used multilevel logistic regression to derive facility rates of predicted SPC for each VAMC adjusting for demographic and clinical characteristics. We examined associations between VAMCs in the top 20% (vs bottom 80%) of SPC rates and family-reported pain at the EOL from the Bereaved Family Survey and the interaction between receiving SPC and VAMC-level SPC rates on study outcomes. Analyses were conducted using generalized linear models, adjusting for demographic, clinical, and facility covariates. Results: The sample was 98% male, 73% White, and 20% Black, with a mean age of 79.7+/−10.3 years. Over 77% of the sample had uncontrolled pain at the EOL. In adjusted models, there was no association between family-reported pain and VAMC rates of SPC (Odds Ratio = 1.082, 95% Confidence Interval = 0.706-1.659). Receipt of SPC did not change this relationship (p-interaction = .405). Conclusion: Families of people with aHF cared for in VAMCs with high rates of SPC were as likely to report uncontrolled pain relative to people cared for in VAMCs with lower SPC rates. Research is needed to identify delivery and organizational features associated with improved pain control at the EOL among this symptomatic population.