Palliative care burden and specialist service utilisation for individuals with cardiovascular disease in Australia: a national population-based observational study

BACKGROUND: Cardiovascular disease (CVD) is a major cause of death globally. In advanced stages, patients with CVD often require palliative care due to reduced health-related quality of life from physical, psychological and spiritual symptoms, along with physical disability. OBJECTIVES: To investigate (1) the symptom and function burden of patients with CVD on their first admission to specialist palliative care services and (2) how these care burdens, and other clinical characteristics, affected patients' utilisation of community-based versus inpatient services. DESIGN: A national population-based observational study using point-of-care outcomes sourced from the Australian palliative care outcomes and collaboration (PCOC). SETTINGS: Community-based and inpatient Specialist palliative care services across Australia registered in the PCOC. PARTICIPANTS: Patients who required specialist palliative care principally for CVD, and whose death occurred between 1 January 2013 and 31 December 2022. METHODS: Five validated clinical instruments were used to collect point-of-care outcomes on each individual's function (Resource Utilisation Groups - Activities of Daily Living (RUG) & Australia-modified Karnofsky Performance Status (AKPS)), symptom distress (Symptoms Assessment Scale & Palliative Care Problem Severity Score) and other clinical characteristics (Palliative Care Phases). Multivariable logistic regression was applied to evaluate how patients' functional and symptom burden influenced their use of inpatient versus community-based palliative care services. RESULTS: Our analysis included 17 002 patients with CVD, with 7539 (44.3%) receiving community palliative care services and 9463 (55.7%) accessing inpatient palliative care services. On admission to palliative care services, patients often exhibit significant physical functional impairments and substantial symptom burdens, particularly related to fatigue and breathing difficulties. In comparison, patients accessing inpatient services tended to have greater functional impairment (p<0.001) but commonly reported lower symptom burdens (p<0.001). Our analysis indicated that greater functional impairment (ORs ranged from 2.53 to 6.02, p<0.001 for RUG; ORs ranged from 1.72 to 5.02, p<0.008 for AKPS), poorer overall health condition (OR ranged from 1.28 to 17.60, p<0.001) and referrals by a community service (OR=0.16, 95% CI: 0.14 to 0.18, p<0.001) were a negative predictor of inpatient services use. Surprisingly, higher levels of symptom distress and challenges in symptom management were associated with a decreased likelihood of using inpatient services compared with community-based services. CONCLUSION: Patients with CVD frequently require support to manage decreased functional abilities, as well as symptoms like fatigue and breathing difficulties. With greater investment in community-based supportive services and a skilled palliative care workforce, more individuals with advanced CVD could potentially receive palliative care in community settings.