Difference-Making Factors Linked to Higher Reach of Specialist Palliative Care Among People with Heart Failure Across a National Sample of VA Medical Centers

Abstract

Background: Palliative Care (SPC) is a guideline-recommended intervention for people with advanced heart failure (aHF). However, there is wide variation in delivery across VA medical centers (VAMCs). This study sought to identify key difference-making features that distinguished VAMCs with high versus lower rates of specialist palliative care (SPC) among this population. Methods: We conducted a secondary analysis of data from the HEART-PAL cohort, comprising 78 high-complexity VAMCs. We used Coincidence Analysis (CNA) to identify minimally necessary and sufficient conditions associated with high (top 25%) or lower (bottom 75%) rates of SPC. Candidate conditions included structures (i.e., full-time equivalents (FTE)) and processes (providing outpatient care), as well as cardiology and facility characteristics. Results: Facility-averaged rates of SPC across VAMCs were 32.7% (standard deviation (SD)=16.28). We identified three pathways to attaining high rates of SPC: above average total team FTE (top 50%) with high numbers of cardiology-initiated consultations (top 25% of consults) OR above average FTE with high use of outpatient palliative care (top 25% of encounters) OR a lower complexity VAMC with above average use of chaplaincy services (Top 50% of visits). In the negative model, there were two pathways to having SPC rates in the bottom 75%: below-average team total FTE, OR the absence of high cardiology-initiated consultations, together with the absence of high outpatient consultations. Conclusion: High SPC reach among people with aHF was linked to combinations of several modifiable factors related to staffing, cardiology involvement, and outpatient palliative care. These findings provide actionable insights into improving SPC delivery across VAMCs.