What is the clinical evidence from this study?

Study design: Cohort. Population: Heart failure and Cancer (n=27689). Intervention: Heart failure vs. Cancer. Primary outcome: Entry onto a palliative care register.

November 25, 2014PLoS ONE118 citationsOpen Access

Palliative Care among Heart Failure Patients in Primary Care: A Comparison to Cancer Patients Using English Family Practice Data

AGAmy Gadoud EKEleanor Kane UMUna Macleod

Key Result

Only 7% of patients with heart failure were entered onto a palliative care register prior to death compared to 48% of patients with cancer.

Study Design

Type

Cohort (n=27,689)

Multicenter

Yes

Structured PICO

Are patients with heart failure less likely to be recognized for palliative care needs compared to patients with cancer in primary care?

Population

27,689 adult patients in England who died in 2009, including 3,122 with heart failure and 7,608 with cancer, evaluated for entry onto a primary care palliative care register.

Exposure

Diagnosis of heart failure

Comparator

Diagnosis of cancer

Outcome

Entry onto a palliative care register as a marker for a palliative approach to care

Patients with heart failure are significantly less likely to be recognized for palliative care needs and are registered much closer to death compared to cancer patients in primary care.

Main Result

Absolute Event Rate: 7% vs 48%

Limitations

Registration on the palliative care QOF is a proxy measure for clinical recognition of the need for a palliative approach to care.
There may be a perception that the palliative care QOF is for cancer patients only.
Denominator may be overestimated as in-life diagnosis data was used rather than cause of death data.
Inability to identify sudden deaths from the CPRD data.

Abstract

INTRODUCTION: Patients with heart failure have a significant symptom burden and other palliative care needs often over a longer period than patients with cancer. It is acknowledged that this need may be unmet but by how much has not been quantified in primary care data at the population level. METHODS: This was the first use of Clinical Practice Research Datalink, the world's largest primary care database to explore recognition of the need for palliative care. Heart failure and cancer patients who had died in 2009 aged 18 or over and had at least one year of primary care records were identified. A palliative approach to care among patients with heart failure was compared to that among patients with cancer using entry onto a palliative care register as a marker for a palliative approach to care. RESULTS: Among patients with heart failure, 7% (234/3 122) were entered on the palliative care register compared to 48% (3 669/7 608) of cancer patients. Of heart failure patients on the palliative care register, 29% (69/234) were entered onto the register within a week of their death. CONCLUSIONS: This confirms that the stark inequity in recognition of palliative care needs for people with heart failure in a large primary care dataset. We recommend a move away from prognosis based criteria for palliative care towards a patient centred approach, with assessment of and attention to palliative needs including advance care planning throughout the disease trajectory.

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