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Advanced Cardiac Disease
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Satisfactory Completion
Learners must complete an evaluation form to receive a certificate of completion. You must participate
in the entire activity as partial credit is not available. If you are seeking continuing education credit for
a specialty not listed below, it is your responsibility to contact your licensing certification board to
determine course eligibility for your licensing certification requirement.
Physicians
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and
VITAS®
Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses
Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation
Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CME Provider Information
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
VITAS® Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board
of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS® Healthcare programs in California/Connecticut/Delaware/ Illinois/Northern/Virginia/Ohio/Pennsylvania/Washington DC/ Wisconsin
are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social
work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education
(ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/2021-06/06/2024). Social Workers
participating in these courses will receive 1 clinical continuing education clock hour. {Counselors/MFT/IMFT are not eligible in Ohio}.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB)
Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education
credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021-06/06/2024. Social workers
completing this course receive 1.0 continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board
of Registered Nursing, Provider Number 10517, expiring 01/31/2025.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH:
No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
CE Provider Information
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
To leverage evidence-based data and case studies to understand
hospice eligibility and benefits for patients with advanced cardiac
disease (ACD) who have a prognosis of ≤ 6 months.
Goal
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
By the end of this presentation, you should be able to:
• Recognize the burden associated with heart failure
• Identify patients with advanced heart failure who are
eligible for hospice through evidence-based research
• Understand palliative interventions for patients with
advanced cardiac disease
• Understand the role of advanced technologies in
end-of-life care
Objectives
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
41.3%
17.2%
9.2%
12.9%
2.6%
16.8%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
Coronary Heart Disease
Stroke
Heart Failure
High Blood Pressure
Diseases of the Arteries
Other
Percent of Total CVD Deaths
Percentage Breakdown of US Deaths Attributable
to Cardiovascular Disease, 20201
Heart Disease in the US
• Heart disease US prevalence 6.7MM
in adults aged 20+1
• Estimated 5-year mortality for those
with HF did not decline from 2000
to 2010 and remained high
–52.6% overall
–24.4% for those 60 years of age
–54.4% for those 80 years of age
• 30-day post-discharge mortality for
Medicare beneficiaries with heart
failure is 8.7%. Heart failure patients
also experience more post-discharge
visits to the ED2
1
Tsao, et al. (2023) American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2023 Update:
A Report From the American Heart Association. Circulation. 2023 Feb 21;147(8):e93-e621.
2Khera, et al. (2020). Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States. British
Medical Journal, 368:6831.
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• On the basis of data from NHANES 2017 to 2020, ≈6.7 million
Americans ≥20 years of age had HF, which is increased from
≈6.0 million according to NHANES 2015 to 2018.1
• Heart Disease as Primary Hospice Diagnosis2
– In 2023, circulatory/heart disease (excluding stroke) was
attributed as the principal diagnosis for 29% of Medicare
beneficiaries enrolled in hospice over 178,000 Medicare
decedents receiving care
– The average lifetime length of hospice care received by
this population was 104 days
Heart Disease and Hospice
1
Tsao, et al. (2023) American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2023
Update: A Report From the American Heart Association. Circulation. 2023 Feb 21;147(8):e93-e621.
2MedPac July 2023 Report to the Congress: Medicare Payment Policy, Chart 11-23. Available at: https://www.medpac.gov/document/july-2023-data-book-health-care-spending-and-the-medicare-program/
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
The Burden of Heart Disease on the US Health System
Adapted from American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035.
Current 2035
Total Direct
(Medical) Costs
$318
billion
$749
billion
Total Indirect
Costs
$237
billion
$368
billion
Projections – CVD Direct and
Indirect Costs Through 2035
$0
$50
$100
$150
$200
$250
2015 2035
Billions
of
Dollars
Projected CVD Direct and Indirect Costs Through 2035 by Condition
Direct. Indirect
CHD CHF Stroke Other
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• 80% with HF are hospitalized
in the last 6 months of life
• Hospital readmission is
21.4% within 30 days
• Almost 50% of patients die
within 5 years of HF diagnosis
Heart Failure Hospital Utilization in the
Last Year of Life
1
Benjamin, et al. (2019) “Heart disease and stroke statistics—2019 update: a report from the American Heart Association.” Circulation 139.10 (2019): e56-e528.
2Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care. Am J Emerg Med. 38(1):89-94.
The number of hospitalizations and days hospitalized prior to death are displayed
for 486 decedents with at least a full year of follow-up from heart failure diagnosis
until death
0
50
100
150
200
250
300
350
331-365 301-330 271-300 241-270 211-240 181-210 151-180 121-150 91-120 61-90 31-60 0-30
Number
of
Hospitalizations
Hospitalizations Days in Hospital
• Healthcare utilization increases as patients near the end of life
• Hospitalizations are most common among home patients and
those with multiple comorbidity, such as PVD, DM, COPD
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Burden of Heart Failure—Symptoms1
1Bekelman, et al. (2009) “Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients.”
Journal of General Internal Medicine 24.5: 592-598.
2MedPac March 2023 Report to the Congress: Medicare Payment Policy, Table 10-3. Available at: https://www.medpac.gov/document/march-2023-report-to-the-
congress-medicare-payment-policy
In 2021, 52.7% of Medicare decedents died without the benefit of hospice services.2
9.4
3.6
35.2
8.7
4.3
36.3
8.7
3.2
39.1
0
5
10
15
20
25
30
35
40
Number of Physical Symptoms* Depression Score† Spiritual Well-Being‡
Heart Failure Low EF Heart Failure Normal EF Advanced Cancer
Is it time to consider a referral
to hospice? Answering these
questions can help:
1. Is the patient facing one of
these life-limiting diseases?
• Cardiac and circulatory diseases
• Alzheimer’s/dementia/Parkinson’s
• Stroke
• Cancer
• Respiratory diseases
2. Is the patient showing signs
of impairment? Consider a referral
to hospice if 2-3 of the following
factors exist:
• Functional decline
• Nutritional decline
• Cognitive decline
• Increased symptom burden
• Increased healthcare utilization
• Progression of underlying disease
3. Have you taken the patient’s
wishes into consideration?
Symptoms = *Measured using the Memorial Symptom Assessment Scale, short form (range, 0–28; higher number indicates more physical symptoms)
Depression Score = †Measured using the Geriatric Depression Scale, short form (range, 0–15, higher score indicates a greater number of depressive symptoms)
Spiritual Well-Being = ‡Measured using the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being scale (scale range, 0–48; higher scores
signifying greater spiritual well-being)
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• Approximately 41.8 million
Americans have provided
unpaid care to an adult age
> 50 in the last 12 months
• Those in high-intensity
caregiving situations more
often report high physical
strain (29%) and higher
emotional stress (49%)
The Burden of Heart Failure on the Family
National Alliance for Caregiving and AARP (2020). Caregiving in the US 2020.
As a result of providing care to your [relation], have you ever experienced
any of these financial Things?
2020 Base: Caregivers of Recipient Age 18+ (n=1,392)
Note: Respondents may select more than one response; results add to greater than 100 percent
Top Financial Impacts as a Result of Caregiving
15%
19%
22%
23%
28%
34%
45%
Borrowed money from family or friends
Left your bills unpaid/paid them late
Use up your personal short-term saving
Took on more debt
Stopped saving
2+ financial impacts
Any of these
% Yes
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
The Burden of Heart Failure on the Family (cont.)
Kitko, et al. on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and
Outcomes Research; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. (2020). Family Caregiving for
Individuals with Heart Failure. Circulation 141:e864–e878.
Multidimensional Burden
• Increased responsibilities
and tasks
• Social isolation
• Financial strain
• Loss of former identity
• Decreased quality of life
Physical Health
• Neglected management
of own health
• Fatigue
• Sleep disruption
• Increased mortality
Psychological Health
• Anxiety
• Depression
• Hypervigilance
• PTSD symptoms
• Coping
Rewards
• Accomplishment
• Satisfaction
• Meaning
Known Relationship-Level Outcomes
• Communication challenges
• Concealment of symptoms/feelings
• Conflict or resentment
• Effects on relationship quality
(strengthened or stressed)
• Changes in sexual
relationship (couples)
Known Caregiver Influence
on Patient Outcomes
• Increased quality of life
• Adherence
• Increased physical function
• Emotional well-being
• Decreased healthcare utilization
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Clinical Course of Heart Failure
Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal, 52.9, 659-679.
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Clinical Course of Heart Failure (cont.)
Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal, 52.9, 659-679.
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Main Symptoms Presented in Heart Failure Patients
Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal ,52.9, 659:679.
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Class Functional Capacity
I
No limitation of physical activity. Ordinary physical activity does not
cause undue fatigue, palpitation, or dyspnea (shortness of breath).
II
Slight limitation of physical activity. Comfortable at rest. Ordinary
physical activity results in fatigue, palpitation, or dyspnea
(shortness of breath).
III
Marked limitation of physical activity. Comfortable at rest. Less
than ordinary activity causes fatigue, palpitation, or dyspnea.
IV
Unable to carry on any physical activity without discomfort.
Symptoms of heart failure at rest. If any physical activity is
undertaken, discomfort increases.
NYHA Classification of Heart Failure
American Heart Association. (2020). Classes of Heart Failure. Retrieved from: https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Stages of Heart Failure
Heidenreich, et al. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart
Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology 79.17 (2022): e263-e421.
Stage A
At-Risk for Heart Failure
Stage B
Pre-Heart Failure
Stage C
Symptoms Heart Failure
Stage D
Advanced Heart Failure
Patients at risk for HF but
without current or previous
symptoms/signs of HF
and without structural/
functional heart disease or
abnormal biomarkers
Patients with hypertension,
CVD, diabetes, obesity,
exposure to cardiotoxic
agents, genetic variant
for cardiomyopathy, or
family history of
cardiomyopathy
Patients without current
or previous symptoms/
signs of HF but evidence
of 1 of the following:
Structural heart disease
Evidence of increased
filling pressure
Risk factors and
• increased natriuretic
peptide levels or
• persistently elevated
cardiac troponin in
the absence of
competing diagnosis
Patients with current
or previous
symptoms/signs
of HF
Marked HF symptoms that
interfere with daily life and
with recurrent hospitalizations
despite attempts to
optimize GDMT
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
HF Outcomes by Type
1Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022.
2Shah, (2017) et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology. 70.20: 2476-2486.
18.7
15.1
11.9
9.1
6.8
5
3.6
2.9
2.3
1.7
1.2 0.8
3.3
2.8 2.6
1.8
1.3 1
4
3.4
2.6 2.2
1.5
0.9
0
2
4
6
8
10
12
14
16
18
20
Median
Survival
in
Years
Median Survival Stratified by Age
Life Expectancy in US HFrEF Patients HFbEF Patients HFpEF Patients
65-69 70-74 75-79 80-84 85-89 ≥90
Age in Years
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
HF Functional Status and Survival
Creber, et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378.
PPS
Score
Ambulation
Activity and
Evidence
of Disease
Self-Care Intake
Conscious
Level
60 Reduced
Unable to do
hobby/housework
Significant disease
Occasional
assistance
necessary
Normal
or
reduced
Full
or
confusion
50
Mainly
sit/lie
Unable to do
any housework
Extensive disease
Considerable
assistance
required
40
Mainly
in bed
Unable to do
most activities
Extensive disease
Mainly
assistance Full or
drowsy
+/-
confusion
30
Totally
bedbound
Unable to do
any activities
Extensive disease
Requires
total care
• Patients with a PPS score of ≤ 50 are generally hospice-eligible; some patients with a higher PPS may also be eligible
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Patient is:
• Optimally treated
• Not a candidate/pursuing
surgical options
Hospice Eligibility Guidelines
NYHA Class IV:
• Symptoms at rest
• Physical activity causes
further discomfort
Functional status and symptom burden are strongest indicators of hospice eligibility
NYHA Class III:
• Symptoms during
less than ordinary activity
• Significant comorbidities
Symptoms include:
• Fatigue
• Dyspnea
• Angina
• Palpitations
Or
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• Uncontrolled
hypertension/hypotension
• Diabetes
• Coronary artery disease
• Prior myocardial infarction
• Valvular heart disease
• Chronic Kidney Disease
• Pulmonary hypertension
due to left-sided HF
(Group 2 PH)*
• Frailty*
Hospice Eligibility Guidelines (cont.)
Significant Comorbidities with Poor Prognosis
*Jimenez-Mendeza et al. Frailty and prognosis of older patients with chronic heart failure. Rev Esp Cardiol. 2022; 75(12):1011-1019
**Meijers et al. Circulating heart failure biomarkers beyond natriuretic peptides: review from the Biomarker Study Group of the Heart Failure Association (HFA), European Society of Cardiology (ESC).
Eur J Heart Fail. 2021 Oct; 23(10): 1610–1632.
† Watanabe et al. Loss of perceived social role, an index of social frailty, is an independent predictor of future adverse events in hospitalized patients with heart failure. Front Cardiovasc Med. 2022;9:1051570.
2022 Dec 20.
• Cognitive impairment*
• Malnutrition*
• Fragility*
• History of malignancy*
• Elevated BNP
• NT-proBNP > 1000 pg/mL*
• Reduced LVEF for patients
with HFrEF
• Elevated cystatin C**
• Dependence on diuretics,
amiodarone, or inotropes*
• Hyponatremia (low sodium)
• Renal dysfunction
• Cachexia
• Ventricular arrhythmias
• History of syncope
or near-syncope
• Social Frailty†
• Older age at
diagnosis of HF*
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• Hospice admission guidelines
are independent of labs and EF
• The question to ask oneself:
“Would I be surprised if the
patient were to die in the
next year? 6 months?”
• Key indicators for a hospice referral:
– Decrease in function
– Increase in patient
symptoms and distress
– Frequent/increased utilization
of medical care, especially
hospitalization and ED visits
• Start the conversation
Hospice Eligibility Guidelines for ACD (cont.)
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Case Study of AM
7 days later
Daughter calls 911. AM is
admitted for HF exacerbation
(NYHA Class IV), receives
IV diuresis for SOB and
congestion. Cardiac
meds are readjusted.
AM improves (NYHA Class III)
and is d/c home with home
health (HH) and physical therapy
(PT) for unsteady gait s/p fall.
3 days later
AM has slightly worsening
SOB and another fall.
Daughter calls PCP, who
recommends same day
hospice evaluation.
14 days ago
AM visits cardiologist for
shortness of breath (SOB),
increased fatigue, and
palpitations. Medications
adjusted with instructions
to f/u in 1 week. Cardiologist
is concerned about
decompensation. Symptoms
worsen despite optimal
medical management.
Medical history
NYHA Class III/IV heart
failure with preserved
EF (HFpEF), LV EF 50%, atrial
fibrillation (A-fib), hypertension,
COPD, and mild dementia
Treatments
Disease-directed
therapy with
diuretics, ACE inhibitors,
oxygen, and nebulizers
Signs/Symptoms
Afebrile, BP 92/64, HR
108 bpm, RR 22, pulse
ox 93% on 2L NC and dyspnea
with minimal exertion, anxiety,
weight loss of 5% over last
month (BMI 20), diffuse
muscle wasting
Patient
AM, 82-year-old female,
compliant with cardiologist
and PCP follow-ups. In the last
6 months, AM has had increased
visits to office due to intensifying
symptom burden and recent fall.
Daughter is primary caregiver
Later that day
A goals-of-care (GOC) conversation
is initiated to realign care with AM
and daughter. AM is not ready to
sign a DNR but is open to a
hospice discussion.
A VITAS admissions nurse meets
with AM and her daughter, and
AM is admitted to hospice same
day. The admissions nurse,
VITAS physician, and AM’s PCP
collaborate to adjust medications
to manage symptoms.
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Pharmacologic Interventions for Heart Failure
Class Name Indication Adverse Effects Comments
Aldosterone Blocker Spironolactone NYHA III or IV
• Hyperkalemia
• Renal dysfunction
Monitor hyperkalemia
ACEi
Enalapril
Lisinopril
Ramipril
HF Stage B-D
• Hyperkalemia
• Renal dysfunction
• Hypotension Angioedema
• Cough
First line for HFrEF
Beta-Blockers
Carvedilol
Metoprolol
• Fatigue
• Hypotension
• Depressed mood
ARBs
Losartan
Valsartan
Candesartan
• Hyperkalemia
• Renal dysfunction
• Hypotension
Substitution for ACE
inhibitors, not with ACEI
Diuretics
Furosemide
Metolazone
Thiazides
Volume overload
• Renal dysfunction
• Frequent urination
• Increase thirst
IV or Sub Q admin
Cardiac Glycosides Digoxin
Arrhythmias;
symptomatic
HF after 1st line
• Cardiac arrhythmias
• Vision changes (green)
• Dizziness, Nausea
• Delirium
Second line for HFrEF
Narrow treatment window
Many contraindications
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Pharmacologic Interventions for Heart Failure
Class Name Indication Adverse Effects Comments
Mineralocorticoid Receptor
Antagonist
Spironolactone
Eplerenone
NYHA II-IV
• Hyperkalemia
• Renal dysfunction
Monitor potassium,
renal function
ARNi
Entresto
(Sacubitril-Valsartan)
NYHA II or III
• Hyperkalemia
• Renal dysfunction
• Dizziness, Fatigue
First-line;
not to be used
with ACEI
Soluble Guanylate Cyclase
Stimulator
Vericiguat
Certain pts w/worsening
HFrEF symptoms
despite GDMT
• Hypotension
• Anemia
Second line
for HFrEF
SA Node Funny Current
Inhibitor
Corlanor/Ivabradine
NYHA II or III HFrEF
• Bradycardia
• Increased BP
• Atrial fibrillation
SA node modulator;
many contraindications
SGLT2 Inhibitor
Farxiga/Dapagliflozin
& others)
NYHA III or IV HF +/- T2DM
• Renal impairment
• UTIs Caution in older adults
Pulmonary HTN
medications
Prostacyclins
Endothelin antagonists
PDE-5 Inhibitors
Pulmonary HTN; improve
exercise ability; slow
progression of PAH
• Anemia
• Respiratory tract infection
• Headache
• Edema
• Nausea
Inhibit vasoconstriction
and/or promotes
vasodilation in
pulmonary circulation
IV, SQ, inhaled, PO
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• No hospital
• Minimal tests
Elements Important to Goals-of-Care Conversation,
Shared Decision-Making
Allen, et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952.
Outcomes Relevant
to Individual Patient
• Improve shortness of breath
• Continue to live at home
• Live as long as
possible
Survival
Costs/Burden
Direct Medical Costs
Indirect Costs
Lost Opportunities
Caregiver Burden
Quality of Life
Symptoms
Physical Function
Mental
Emotional
Social
Advanced Cardiac Disease Is your patient hospice eligible? VITAS can help. Confidential and Proprietary Content
Earlier goals of care and prognostication for hospice eligibility improved quality of life,
allowed AM to remain in her preferred care setting, and prevented hospital readmissions. Visits:
• RN: 33
• CNA: 48
• MD: 3
• SW: 2
• Chaplain: 2
• Vol: 2
• OT: 2
• RT: 2
AM Care Summary:
• Total visits: 94
• Total Telecare calls: 12
• Total LOC changes: 2
• Total days of ICC®
: 7
• Total meds: 8
• Total HME: 5
Total days of care: 109
How AM’s quality of life
improved as a result of
earlier hospice
identification and referral:
VITAS RN performs
same-day home
admission
AM experiences
increased SOB and HF
exacerbation. Intensive
Comfort Care®
(ICC)
initiated at home.
AM dies
at home
AM placed on
routine care and
her symptoms/
quality of life improve
AM experiences
ongoing decline and
worsening SOB.
ICC initiated
at home
AM’s symptoms
improve, and
she is placed
on routine care
60
Days
4
Days
PCP
Referral
3
Days
42
Days
SQ Lasix, O2,
titrated cardiac
meds, and opioids
Meds and treatments
adjusted for comfort.
RT, SW, and chaplain
visit for support
Daughter receives
bereavement
support
Case of AM Hospice and Timely Prognostication
Later
That Day
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Association of Hospice Admission With Rehospitalization
Kheirbek, et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure.
Circulation: Heart Failure, 8(4), 733-740.
• 41% of the heart failure patients
who died within 6 months of hospital
discharge without hospice had at
least one rehospitalization within
30 days
• Only 5% of heart failure patients
who died within 6 months and
were admitted to hospice were
rehospitalized within 30 days
• Only 10% of patients who died
within 6 months after hospital
discharge were referred
to hospice
Patients Who Received Hospice Had Significantly
Lower 30-Day All-Cause Readmission Rates
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Published Literature and Research Reinforce the Experiential
Value that Hospice Provides to Patients, Families, and Caregivers
Kleinpell, et al. (2019). Exploring the association of hospice care on patient experience and outcomes of care. BMJ Supportive & Palliative Care, 9(1), e13-e13.
Harrison, et al. (2022). Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life: Study examines hospice care quality for older adults with dementia in their last month of life. Health Affairs, 41(6), 821-830.
Wright, et al. (2010). Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. Journal of Clinical Oncology, 28(29), 4457.
Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432.
Families remarked patients received
just the right amount of pain medicine
and help with dyspnea
Families of patients receiving >30
days of hospice reported the most
positive EOL outcomes
Families more often reported patients’ EOL
wishes were followed and rated quality of
EOL care as excellent
Family
Less risk for PTSD
with home hospice
deaths**
Home hospice reduced risk
for prolonged grief disorder***
Hospice admission in last 6 months of
life correlated with increases in patient
satisfaction and better pain control,
reductions in hospital days
Less physical and emotional
distress and better quality of
life at EOL*
Caregivers
Patients
Hospice beneficiaries saw
a cost savings of $670 in
out-of-pocket expenses during
the last month of life compared
to non-hospice users
*Cancer patients, when comparing death in hospital to death in hospice **Compared to death in ICU ***Compared to hospital deaths
60% reduction in end-of-life transitions, allowing patients to die in location of choice
Advanced Cardiac Disease Is your patient hospice eligible? VITAS can help. Confidential and Proprietary Content
Total Cost of Care Comparison by Disease State and Hospice
Use in Last Year of Life*
*To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered
to be terminally ill if the medical prognosis is that the individual’s life expectancy is 6 months or less if the illness runs its normal course. Only care provided by (or under
arrangements made by) a Medicare certified hospice is covered under the Medicare hospice benefit. The hospice admits a patient only on the recommendation of the
medical director in consultation with, or with input from, the patient's attending physician, nurse practitioner, physician assistant, and/or physician.
NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf
Spending is greater than Spending is less than
non-hospice users non-hospice users
No Difference / Not
Statistically Significant
• Hospice care saved
Medicare approximately
$3.5 billion for patients in
their last year of life
• Those patients with
circulatory disease that
had a hospice stay of
even ≥ 2 weeks yielded
a significant cost savings
– For circulatory patients
whose hospice stays
were between 181-266
days, total cost of care
was more than $5K less
than non-hospice users
– Circulatory patients with
stays of > 266 days
spent nearly $7K less
than non-hospice users
Disease
Group
No
Hospice
Hospice
< 15 Days 15 – 30 31 – 60 61 – 90 91 – 180 181 – 266 > 266
ALL $67,192 4% -5% -9% -12% -14% -10% -12%
Circulatory $66,041 7% -4% -8% -10% -11% -8% -10%
Cancer $76,625 10% -1% -6% -9% -13% -14% -20%
Neuro-
degenerative
$61,004 12% -6% -9% -11% -11% -5% -4%
Respiratory $77,892 -2% -11% -14% -17% -19% -18% -22%
CKD/ESRD $82,781 1% -14% -21% -24% -24% -23% -27%
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
NORC’s Analysis Found That Hospice Spending for All Disease Groups is
11% Lower Compared to Non-hospice Users for Stays Exceeding 6 Months
NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Comprehensive Services
VITAS Palliative Care Home Health
Eligibility Requirements
Prognosis required: ≤ 6 months if
the illness runs its usual course
Prognosis varies by program,
usually life-defining illness
Prognosis not required
Skilled need not required Skilled need not required Skilled need required
Plan of Care Quality of life and defined goals Quality of life and defined goals Restorative care
Length of Care Unlimited Variable Limited, with requirements
Homebound Not required Not required Required, with exceptions
Targeted Disease-Specific
Program
✓ Variable Variable
Medications Included ✓ X X
Equipment Included ✓ X X
After-Hours Staff Availability ✓ X X
RT/PT/OT/Speech ✓ X ✓
Nurse Visit Frequency Unlimited Variable Limited, based on diagnosis
Palliative Care Physician Support ✓ Variable X
Levels of Care 4 1 1
Bereavement Support ✓ X X
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• Unpredictable trajectory
• Patient overestimates survival
• Physicians overestimate survival
• Frequent exacerbations
• Hospitalized HF patient lacks DNR status
• Patient misunderstands hospice
• Physicians misunderstand hospice
• Prognostication proves challenging
• “Treatments are discontinued in hospice”
Discomfort
around EOL
issues
Communication
breakdown
Misinformation
Patients’ and Clinicians’ Barriers to Hospice
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Advanced interventions may be appropriate to palliate symptoms
of ACD in hospice and must be discussed with the Hospice
Medical Director prior to admission.
• These may include:
– Parenteral diuretics
– IV inotropes
– Pacemaker or cardiac resynchronization therapy (CRT)
– Ventricular assist device (VAD)
• A defibrillator is not palliative
Advanced Cardiac Interventions in Hospice
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• Diuretics can be administered IV
or SQ
• SQ diuretics can eliminate the
need for an IV for patients at home
• Similar outcomes between SQ and IV
– Similar diuresis
– No difference in rehospitalizations
• Dosing can be continuous or
intermittent infusion
• Limited data in severely obese and
end-stage kidney disease
• Local side effects can occur:
tingling, burning, swelling
Advanced Interventions – Parenteral Diuretics
Afari, et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review. Heart Failure Reviews, 24(3), 309-313.
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Advanced Interventions – Inotropes
Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616.
IV inotropes may be used for
palliation of symptoms in select
patients with advanced HF who
are not candidates for MCS
or transplant
• Improve NYHA Class
(Functional Capacity)
• No association with mortality
or hospitalization
• May increase risk of
ICD shock
Considerations for hospice:
• Hospice may provide inotropes
for palliation of symptoms
• Cardiologist should be involved
• Requires more permanent
central venous access
• Fixed dose, no up-titration
• Patient/family agreeable to
hospice plan of care (symptom-
based, no cardiac monitor)
• Typically admitted to hospice
on continuous care
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Advanced Interventions – Inotropes (cont.)
Ginwalla, et al. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448.
Name
Mechanism
of Action
Primary
Effects
Maintenance
Dose
Benefits
Risks/
Adverse
Effects
Significant
Adverse
Reaction
Indications for
Discontinuation
Dobutamine
Stimulates
Beta-1 and
Beta-2 receptors
Inotropic and
chronotropic
2-20
mcg/kg/min
Slows heart rate
and strengthens
cardiac
contractility
Reduces
sinoatrial
firing rate
Reduces atrial
fibrillation and
ventricular flutter
Increases
ejection fraction
Decreases
pulmonary
congestion
Tachycardia
Dizziness
Nausea and
vomiting
Anorexia
Blurred
vision
Interacts
with many
meds and
most
OTC drugs
•PVC’s
•Palpitations
•Headache
•Nausea
Side effects
outweigh benefits
Patient request
(requires goals of care
discussion)
Refractory to inotrope/
Tolerance
Develop HF symptoms
Milrinone
Phosphodiesterase
III Inhibitor
Inotropic,
arterial and
venous
dilation
0.375-0.75
mcg/kg/min
•Arrhythmias
•Hypotension
•Angina
•Hypokalemia
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Type Indication Benefits Burdens Comments/Reasoning
Pacemakers/
CRTs
Both:
• Symptomatic bradycardia
• 2○
or 3○
heart block
CRT only:
• NYHA Class III and IV
• Certain Class II patients
Improves:
• Symptoms of heart disease
• Quality of life
• Cardiac function
All:
•Battery lifespan
•Infection (rare)
•Malfunction (rare)
•Poorer outcomes1:
–Typically placed in patients who
are > 90 y/o, renal failure, active
malignancy, connective tissue
disorder, dementia
cerebrovascular disease,
AICD only:
•Risk of traumatic death
Life expectancy of years
Rare to discontinue–may
result in acute HF
exacerbation
Not palliative
Recommend to deactivate
when patient has
advanced illness
Defibrillators/
AICDs
High risk of life-threatening
arrhythmias
Delivers shock
to convert to normal rhythm
Fewer hospitalizations
VADs
(LVAD, RVAD,
BiVAD)
Advancing HF despite
maximal medical therapy–
Bridge to transplant/
decision/recovery or
destination therapy
Improves:
• HF symptoms
• Quality of life
Complications:
• Stroke
• Infection
• Sepsis/pneumonia
• Serious bleeds
• Pump malfunction (rare)
External battery must always
be connected
LVAD does not improve
1-yr survival but does show
significant symptom benefit
over OMM after 1 yr
Improved survival with
continuous flow2
:
• 78% at 1 yr
• 45% at 4 yrs
Mechanical Interventions
1Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin.
2Balla, et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65:37-34.
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
• Determine goals of care:
what is important?
• Manage symptoms holistically
– Psychosocial interventions
– Nonpharmacologic interventions
– Medications
• Avoid suffering and prolongation
of dying
• Achieve a sense of control
• Relieve burdens
• Strengthen relationship with
loved ones
The Role of Hospice in ACD
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Trajectories After LVAD Implantation
DeFilippis, et al. (2019). Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions.
Journal of the American Geriatrics Society, 67(11), 2410–2419. https://doi.org/10.1111/jgs.16105
1
Preimplantation advanced
care planning
Inpatient support, symptom
management
Review of progress and goals
of care, symptom management
Triggered revisiting of goals
of care
Bereavement support
1
2
3
4
5
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Caring for a patient with a VAD is
fundamentally no different than
caring for a patient without a VAD
• Hospice team trained in VAD-
specific symptom management,
differences in physical exam,
technical concerns
• Hospice and cardiology teams
collaborate closely
• Address any patient and family concerns
• Majority of VAD patients die with their
VAD still functioning
Elective discontinuation of VAD is a
treatment option, decision made with
treatment teams
• Clinical indications for VAD deactivation
– VAD failure or complications
– Poor quality of life despite VAD
– Advanced comorbid conditions
• Can occur at home or inpatient unit
– Clinical and psychosocial team
involvement
– Survival after deactivation ranges from
minutes to days (average 20 minutes)
VADs and Hospice
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
In Summary
• Heart Failure causes significant burden
to patients and their caregivers, as well
as the healthcare system
• Patients with HF are generally eligible
for hospice when they are mainly
in bed or chair and have symptoms
with less-than-normal activity
• Hospice can help patients stay
in their preferred setting by
preventing hospitalizations
• Hospice can prevent and alleviate
suffering – physical, emotional,
spiritual – with nonpharmacologic
interventions, medications, and
advanced interventions, for patients
with advanced heart disease
Questions
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Afari, et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review. Heart failure reviews,
24(3), 309-313.
Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care.
Am J Emerg Med. 38(1), 89-94.
Allen, L. A., et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association.
Circulation, 125(15), 1928-1952.
American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035.
American Heart Association. (2020). Classes of Heart Failure. Retrieved from: https://www.heart.org/en/health-topics/
heart-failure/what-is-heart- failure/classes-of-heart-failure
American Heart Association. (2022). 2022 Heart Disease and Stroke Statistics Update Fact Sheet At-a-Glance. Available at:
https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2022-Heart-and-Stroke-Stat-Update/2022-Stat-Update-
At-a-Glance.pdf
Balla, C., et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65: 37- 43.
Bekelman, D., et al. (2009). Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced
cancer patients. Journal of General Internal Medicine, 24(5), 592-598.
Benjamin E., et al. (2019). Heart disease and stroke statistics: 2019 update. Circulation, 139(10):e56–528.
Creber, et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart
failure. ESC Heart Failure, 6(2), 371-378.
DeFilippis, et al. (2019). Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions.
Journal of the American Geriatrics Society, 67(11), 2410–2419.
References
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Ginwalla, et al. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448.
Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616.
Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One,
7(7), e41022.
Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin.
Harrison, et al. (2022). Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life: Study examines
hospice care quality for older adults with dementia in their last month of life. Health Affairs, 41(6), 821-830.
Heidenreich, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of
Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of
Cardiology 79.17, e263-e421.
Kheirbek, et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized
for heart failure. Circulation: Heart Failure, 8(4), 733-740.
Khera, R., et al. (2020). Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective
cohort study of Medicare beneficiaries in the United States. British Medical Journal, 368:6831
Kitko, et al. on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Quality of
Care and Outcomes Research; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. (2020).
Family Caregiving for Individuals with Heart Failure. Circulation. 141: e864–e878.
Kleinpell, et al. (2019). Exploring the association of hospice care on patient experience and outcomes of care. BMJ Supportive
& Palliative Care, 9(1), e13-e13.
References
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology,
35(4), 432.
Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal, 52.9, 659-679.
MedPac July 2023 Report to the Congress: Medicare Payment Policy, Chart 11-23. Available at: https://www.medpac.gov/
document/july-2023-data-book-health-care-spending-and-the-medicare-program/
MedPac March 2023 Report to the Congress: Medicare Payment Policy, Table 10-3. Available at: https://www.medpac.gov/
document/march-2023-report-to-thecongress-medicare-payment-policy
Mclluennan, et al. (2016). Palliative care in patients with heart failure. British Medical Journal, 6:352.
National Alliance for Caregiving and AARP. Caregiving in the US 2020.
NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/
wp-content/uploads/Value_Hospice_in_Medicare.pdf
NHPCO. (2023). Facts and Figures: Hospice Care in America.
Shah, et al. (2017) Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the
American College of Cardiology. 70.20: 2476-2486
Tsao, et al. (2023) American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke
Statistics Subcommittee. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association.
Circulation. 2023 Feb 21;147(8):e93-e621.
Wright, et al. (2010). Place of death: correlations with quality of life of patients with cancer and predictors of bereaved
caregivers' mental health. Journal of Clinical Oncology, 28(29), 4457.
References
Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content

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Advanced Cardiac Disease | VITAS Healthcare

  • 2. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Satisfactory Completion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing certification board to determine course eligibility for your licensing certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. CME Provider Information
  • 3. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content VITAS® Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS® Healthcare programs in California/Connecticut/Delaware/ Illinois/Northern/Virginia/Ohio/Pennsylvania/Washington DC/ Wisconsin are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/2021-06/06/2024). Social Workers participating in these courses will receive 1 clinical continuing education clock hour. {Counselors/MFT/IMFT are not eligible in Ohio}. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021-06/06/2024. Social workers completing this course receive 1.0 continuing education credits. VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2025. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois. CE Provider Information
  • 4. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content To leverage evidence-based data and case studies to understand hospice eligibility and benefits for patients with advanced cardiac disease (ACD) who have a prognosis of ≤ 6 months. Goal
  • 5. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content By the end of this presentation, you should be able to: • Recognize the burden associated with heart failure • Identify patients with advanced heart failure who are eligible for hospice through evidence-based research • Understand palliative interventions for patients with advanced cardiac disease • Understand the role of advanced technologies in end-of-life care Objectives
  • 6. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content 41.3% 17.2% 9.2% 12.9% 2.6% 16.8% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Coronary Heart Disease Stroke Heart Failure High Blood Pressure Diseases of the Arteries Other Percent of Total CVD Deaths Percentage Breakdown of US Deaths Attributable to Cardiovascular Disease, 20201 Heart Disease in the US • Heart disease US prevalence 6.7MM in adults aged 20+1 • Estimated 5-year mortality for those with HF did not decline from 2000 to 2010 and remained high –52.6% overall –24.4% for those 60 years of age –54.4% for those 80 years of age • 30-day post-discharge mortality for Medicare beneficiaries with heart failure is 8.7%. Heart failure patients also experience more post-discharge visits to the ED2 1 Tsao, et al. (2023) American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation. 2023 Feb 21;147(8):e93-e621. 2Khera, et al. (2020). Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States. British Medical Journal, 368:6831.
  • 7. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • On the basis of data from NHANES 2017 to 2020, ≈6.7 million Americans ≥20 years of age had HF, which is increased from ≈6.0 million according to NHANES 2015 to 2018.1 • Heart Disease as Primary Hospice Diagnosis2 – In 2023, circulatory/heart disease (excluding stroke) was attributed as the principal diagnosis for 29% of Medicare beneficiaries enrolled in hospice over 178,000 Medicare decedents receiving care – The average lifetime length of hospice care received by this population was 104 days Heart Disease and Hospice 1 Tsao, et al. (2023) American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation. 2023 Feb 21;147(8):e93-e621. 2MedPac July 2023 Report to the Congress: Medicare Payment Policy, Chart 11-23. Available at: https://www.medpac.gov/document/july-2023-data-book-health-care-spending-and-the-medicare-program/
  • 8. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content The Burden of Heart Disease on the US Health System Adapted from American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035. Current 2035 Total Direct (Medical) Costs $318 billion $749 billion Total Indirect Costs $237 billion $368 billion Projections – CVD Direct and Indirect Costs Through 2035 $0 $50 $100 $150 $200 $250 2015 2035 Billions of Dollars Projected CVD Direct and Indirect Costs Through 2035 by Condition Direct. Indirect CHD CHF Stroke Other
  • 9. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • 80% with HF are hospitalized in the last 6 months of life • Hospital readmission is 21.4% within 30 days • Almost 50% of patients die within 5 years of HF diagnosis Heart Failure Hospital Utilization in the Last Year of Life 1 Benjamin, et al. (2019) “Heart disease and stroke statistics—2019 update: a report from the American Heart Association.” Circulation 139.10 (2019): e56-e528. 2Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care. Am J Emerg Med. 38(1):89-94. The number of hospitalizations and days hospitalized prior to death are displayed for 486 decedents with at least a full year of follow-up from heart failure diagnosis until death 0 50 100 150 200 250 300 350 331-365 301-330 271-300 241-270 211-240 181-210 151-180 121-150 91-120 61-90 31-60 0-30 Number of Hospitalizations Hospitalizations Days in Hospital • Healthcare utilization increases as patients near the end of life • Hospitalizations are most common among home patients and those with multiple comorbidity, such as PVD, DM, COPD
  • 10. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Burden of Heart Failure—Symptoms1 1Bekelman, et al. (2009) “Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients.” Journal of General Internal Medicine 24.5: 592-598. 2MedPac March 2023 Report to the Congress: Medicare Payment Policy, Table 10-3. Available at: https://www.medpac.gov/document/march-2023-report-to-the- congress-medicare-payment-policy In 2021, 52.7% of Medicare decedents died without the benefit of hospice services.2 9.4 3.6 35.2 8.7 4.3 36.3 8.7 3.2 39.1 0 5 10 15 20 25 30 35 40 Number of Physical Symptoms* Depression Score† Spiritual Well-Being‡ Heart Failure Low EF Heart Failure Normal EF Advanced Cancer Is it time to consider a referral to hospice? Answering these questions can help: 1. Is the patient facing one of these life-limiting diseases? • Cardiac and circulatory diseases • Alzheimer’s/dementia/Parkinson’s • Stroke • Cancer • Respiratory diseases 2. Is the patient showing signs of impairment? Consider a referral to hospice if 2-3 of the following factors exist: • Functional decline • Nutritional decline • Cognitive decline • Increased symptom burden • Increased healthcare utilization • Progression of underlying disease 3. Have you taken the patient’s wishes into consideration? Symptoms = *Measured using the Memorial Symptom Assessment Scale, short form (range, 0–28; higher number indicates more physical symptoms) Depression Score = †Measured using the Geriatric Depression Scale, short form (range, 0–15, higher score indicates a greater number of depressive symptoms) Spiritual Well-Being = ‡Measured using the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being scale (scale range, 0–48; higher scores signifying greater spiritual well-being)
  • 11. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • Approximately 41.8 million Americans have provided unpaid care to an adult age > 50 in the last 12 months • Those in high-intensity caregiving situations more often report high physical strain (29%) and higher emotional stress (49%) The Burden of Heart Failure on the Family National Alliance for Caregiving and AARP (2020). Caregiving in the US 2020. As a result of providing care to your [relation], have you ever experienced any of these financial Things? 2020 Base: Caregivers of Recipient Age 18+ (n=1,392) Note: Respondents may select more than one response; results add to greater than 100 percent Top Financial Impacts as a Result of Caregiving 15% 19% 22% 23% 28% 34% 45% Borrowed money from family or friends Left your bills unpaid/paid them late Use up your personal short-term saving Took on more debt Stopped saving 2+ financial impacts Any of these % Yes
  • 12. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content The Burden of Heart Failure on the Family (cont.) Kitko, et al. on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. (2020). Family Caregiving for Individuals with Heart Failure. Circulation 141:e864–e878. Multidimensional Burden • Increased responsibilities and tasks • Social isolation • Financial strain • Loss of former identity • Decreased quality of life Physical Health • Neglected management of own health • Fatigue • Sleep disruption • Increased mortality Psychological Health • Anxiety • Depression • Hypervigilance • PTSD symptoms • Coping Rewards • Accomplishment • Satisfaction • Meaning Known Relationship-Level Outcomes • Communication challenges • Concealment of symptoms/feelings • Conflict or resentment • Effects on relationship quality (strengthened or stressed) • Changes in sexual relationship (couples) Known Caregiver Influence on Patient Outcomes • Increased quality of life • Adherence • Increased physical function • Emotional well-being • Decreased healthcare utilization
  • 13. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Clinical Course of Heart Failure Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal, 52.9, 659-679.
  • 14. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Clinical Course of Heart Failure (cont.) Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal, 52.9, 659-679.
  • 15. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Main Symptoms Presented in Heart Failure Patients Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal ,52.9, 659:679.
  • 16. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Class Functional Capacity I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath). II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, or dyspnea (shortness of breath). III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea. IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases. NYHA Classification of Heart Failure American Heart Association. (2020). Classes of Heart Failure. Retrieved from: https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure
  • 17. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Stages of Heart Failure Heidenreich, et al. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology 79.17 (2022): e263-e421. Stage A At-Risk for Heart Failure Stage B Pre-Heart Failure Stage C Symptoms Heart Failure Stage D Advanced Heart Failure Patients at risk for HF but without current or previous symptoms/signs of HF and without structural/ functional heart disease or abnormal biomarkers Patients with hypertension, CVD, diabetes, obesity, exposure to cardiotoxic agents, genetic variant for cardiomyopathy, or family history of cardiomyopathy Patients without current or previous symptoms/ signs of HF but evidence of 1 of the following: Structural heart disease Evidence of increased filling pressure Risk factors and • increased natriuretic peptide levels or • persistently elevated cardiac troponin in the absence of competing diagnosis Patients with current or previous symptoms/signs of HF Marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize GDMT
  • 18. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content HF Outcomes by Type 1Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022. 2Shah, (2017) et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology. 70.20: 2476-2486. 18.7 15.1 11.9 9.1 6.8 5 3.6 2.9 2.3 1.7 1.2 0.8 3.3 2.8 2.6 1.8 1.3 1 4 3.4 2.6 2.2 1.5 0.9 0 2 4 6 8 10 12 14 16 18 20 Median Survival in Years Median Survival Stratified by Age Life Expectancy in US HFrEF Patients HFbEF Patients HFpEF Patients 65-69 70-74 75-79 80-84 85-89 ≥90 Age in Years
  • 19. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content HF Functional Status and Survival Creber, et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378. PPS Score Ambulation Activity and Evidence of Disease Self-Care Intake Conscious Level 60 Reduced Unable to do hobby/housework Significant disease Occasional assistance necessary Normal or reduced Full or confusion 50 Mainly sit/lie Unable to do any housework Extensive disease Considerable assistance required 40 Mainly in bed Unable to do most activities Extensive disease Mainly assistance Full or drowsy +/- confusion 30 Totally bedbound Unable to do any activities Extensive disease Requires total care • Patients with a PPS score of ≤ 50 are generally hospice-eligible; some patients with a higher PPS may also be eligible
  • 20. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Patient is: • Optimally treated • Not a candidate/pursuing surgical options Hospice Eligibility Guidelines NYHA Class IV: • Symptoms at rest • Physical activity causes further discomfort Functional status and symptom burden are strongest indicators of hospice eligibility NYHA Class III: • Symptoms during less than ordinary activity • Significant comorbidities Symptoms include: • Fatigue • Dyspnea • Angina • Palpitations Or
  • 21. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • Uncontrolled hypertension/hypotension • Diabetes • Coronary artery disease • Prior myocardial infarction • Valvular heart disease • Chronic Kidney Disease • Pulmonary hypertension due to left-sided HF (Group 2 PH)* • Frailty* Hospice Eligibility Guidelines (cont.) Significant Comorbidities with Poor Prognosis *Jimenez-Mendeza et al. Frailty and prognosis of older patients with chronic heart failure. Rev Esp Cardiol. 2022; 75(12):1011-1019 **Meijers et al. Circulating heart failure biomarkers beyond natriuretic peptides: review from the Biomarker Study Group of the Heart Failure Association (HFA), European Society of Cardiology (ESC). Eur J Heart Fail. 2021 Oct; 23(10): 1610–1632. † Watanabe et al. Loss of perceived social role, an index of social frailty, is an independent predictor of future adverse events in hospitalized patients with heart failure. Front Cardiovasc Med. 2022;9:1051570. 2022 Dec 20. • Cognitive impairment* • Malnutrition* • Fragility* • History of malignancy* • Elevated BNP • NT-proBNP > 1000 pg/mL* • Reduced LVEF for patients with HFrEF • Elevated cystatin C** • Dependence on diuretics, amiodarone, or inotropes* • Hyponatremia (low sodium) • Renal dysfunction • Cachexia • Ventricular arrhythmias • History of syncope or near-syncope • Social Frailty† • Older age at diagnosis of HF*
  • 22. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • Hospice admission guidelines are independent of labs and EF • The question to ask oneself: “Would I be surprised if the patient were to die in the next year? 6 months?” • Key indicators for a hospice referral: – Decrease in function – Increase in patient symptoms and distress – Frequent/increased utilization of medical care, especially hospitalization and ED visits • Start the conversation Hospice Eligibility Guidelines for ACD (cont.)
  • 23. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Case Study of AM 7 days later Daughter calls 911. AM is admitted for HF exacerbation (NYHA Class IV), receives IV diuresis for SOB and congestion. Cardiac meds are readjusted. AM improves (NYHA Class III) and is d/c home with home health (HH) and physical therapy (PT) for unsteady gait s/p fall. 3 days later AM has slightly worsening SOB and another fall. Daughter calls PCP, who recommends same day hospice evaluation. 14 days ago AM visits cardiologist for shortness of breath (SOB), increased fatigue, and palpitations. Medications adjusted with instructions to f/u in 1 week. Cardiologist is concerned about decompensation. Symptoms worsen despite optimal medical management. Medical history NYHA Class III/IV heart failure with preserved EF (HFpEF), LV EF 50%, atrial fibrillation (A-fib), hypertension, COPD, and mild dementia Treatments Disease-directed therapy with diuretics, ACE inhibitors, oxygen, and nebulizers Signs/Symptoms Afebrile, BP 92/64, HR 108 bpm, RR 22, pulse ox 93% on 2L NC and dyspnea with minimal exertion, anxiety, weight loss of 5% over last month (BMI 20), diffuse muscle wasting Patient AM, 82-year-old female, compliant with cardiologist and PCP follow-ups. In the last 6 months, AM has had increased visits to office due to intensifying symptom burden and recent fall. Daughter is primary caregiver Later that day A goals-of-care (GOC) conversation is initiated to realign care with AM and daughter. AM is not ready to sign a DNR but is open to a hospice discussion. A VITAS admissions nurse meets with AM and her daughter, and AM is admitted to hospice same day. The admissions nurse, VITAS physician, and AM’s PCP collaborate to adjust medications to manage symptoms.
  • 24. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Pharmacologic Interventions for Heart Failure Class Name Indication Adverse Effects Comments Aldosterone Blocker Spironolactone NYHA III or IV • Hyperkalemia • Renal dysfunction Monitor hyperkalemia ACEi Enalapril Lisinopril Ramipril HF Stage B-D • Hyperkalemia • Renal dysfunction • Hypotension Angioedema • Cough First line for HFrEF Beta-Blockers Carvedilol Metoprolol • Fatigue • Hypotension • Depressed mood ARBs Losartan Valsartan Candesartan • Hyperkalemia • Renal dysfunction • Hypotension Substitution for ACE inhibitors, not with ACEI Diuretics Furosemide Metolazone Thiazides Volume overload • Renal dysfunction • Frequent urination • Increase thirst IV or Sub Q admin Cardiac Glycosides Digoxin Arrhythmias; symptomatic HF after 1st line • Cardiac arrhythmias • Vision changes (green) • Dizziness, Nausea • Delirium Second line for HFrEF Narrow treatment window Many contraindications
  • 25. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Pharmacologic Interventions for Heart Failure Class Name Indication Adverse Effects Comments Mineralocorticoid Receptor Antagonist Spironolactone Eplerenone NYHA II-IV • Hyperkalemia • Renal dysfunction Monitor potassium, renal function ARNi Entresto (Sacubitril-Valsartan) NYHA II or III • Hyperkalemia • Renal dysfunction • Dizziness, Fatigue First-line; not to be used with ACEI Soluble Guanylate Cyclase Stimulator Vericiguat Certain pts w/worsening HFrEF symptoms despite GDMT • Hypotension • Anemia Second line for HFrEF SA Node Funny Current Inhibitor Corlanor/Ivabradine NYHA II or III HFrEF • Bradycardia • Increased BP • Atrial fibrillation SA node modulator; many contraindications SGLT2 Inhibitor Farxiga/Dapagliflozin & others) NYHA III or IV HF +/- T2DM • Renal impairment • UTIs Caution in older adults Pulmonary HTN medications Prostacyclins Endothelin antagonists PDE-5 Inhibitors Pulmonary HTN; improve exercise ability; slow progression of PAH • Anemia • Respiratory tract infection • Headache • Edema • Nausea Inhibit vasoconstriction and/or promotes vasodilation in pulmonary circulation IV, SQ, inhaled, PO
  • 26. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • No hospital • Minimal tests Elements Important to Goals-of-Care Conversation, Shared Decision-Making Allen, et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952. Outcomes Relevant to Individual Patient • Improve shortness of breath • Continue to live at home • Live as long as possible Survival Costs/Burden Direct Medical Costs Indirect Costs Lost Opportunities Caregiver Burden Quality of Life Symptoms Physical Function Mental Emotional Social
  • 27. Advanced Cardiac Disease Is your patient hospice eligible? VITAS can help. Confidential and Proprietary Content Earlier goals of care and prognostication for hospice eligibility improved quality of life, allowed AM to remain in her preferred care setting, and prevented hospital readmissions. Visits: • RN: 33 • CNA: 48 • MD: 3 • SW: 2 • Chaplain: 2 • Vol: 2 • OT: 2 • RT: 2 AM Care Summary: • Total visits: 94 • Total Telecare calls: 12 • Total LOC changes: 2 • Total days of ICC® : 7 • Total meds: 8 • Total HME: 5 Total days of care: 109 How AM’s quality of life improved as a result of earlier hospice identification and referral: VITAS RN performs same-day home admission AM experiences increased SOB and HF exacerbation. Intensive Comfort Care® (ICC) initiated at home. AM dies at home AM placed on routine care and her symptoms/ quality of life improve AM experiences ongoing decline and worsening SOB. ICC initiated at home AM’s symptoms improve, and she is placed on routine care 60 Days 4 Days PCP Referral 3 Days 42 Days SQ Lasix, O2, titrated cardiac meds, and opioids Meds and treatments adjusted for comfort. RT, SW, and chaplain visit for support Daughter receives bereavement support Case of AM Hospice and Timely Prognostication Later That Day
  • 28. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Association of Hospice Admission With Rehospitalization Kheirbek, et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure. Circulation: Heart Failure, 8(4), 733-740. • 41% of the heart failure patients who died within 6 months of hospital discharge without hospice had at least one rehospitalization within 30 days • Only 5% of heart failure patients who died within 6 months and were admitted to hospice were rehospitalized within 30 days • Only 10% of patients who died within 6 months after hospital discharge were referred to hospice Patients Who Received Hospice Had Significantly Lower 30-Day All-Cause Readmission Rates
  • 29. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Published Literature and Research Reinforce the Experiential Value that Hospice Provides to Patients, Families, and Caregivers Kleinpell, et al. (2019). Exploring the association of hospice care on patient experience and outcomes of care. BMJ Supportive & Palliative Care, 9(1), e13-e13. Harrison, et al. (2022). Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life: Study examines hospice care quality for older adults with dementia in their last month of life. Health Affairs, 41(6), 821-830. Wright, et al. (2010). Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. Journal of Clinical Oncology, 28(29), 4457. Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432. Families remarked patients received just the right amount of pain medicine and help with dyspnea Families of patients receiving >30 days of hospice reported the most positive EOL outcomes Families more often reported patients’ EOL wishes were followed and rated quality of EOL care as excellent Family Less risk for PTSD with home hospice deaths** Home hospice reduced risk for prolonged grief disorder*** Hospice admission in last 6 months of life correlated with increases in patient satisfaction and better pain control, reductions in hospital days Less physical and emotional distress and better quality of life at EOL* Caregivers Patients Hospice beneficiaries saw a cost savings of $670 in out-of-pocket expenses during the last month of life compared to non-hospice users *Cancer patients, when comparing death in hospital to death in hospice **Compared to death in ICU ***Compared to hospital deaths 60% reduction in end-of-life transitions, allowing patients to die in location of choice
  • 30. Advanced Cardiac Disease Is your patient hospice eligible? VITAS can help. Confidential and Proprietary Content Total Cost of Care Comparison by Disease State and Hospice Use in Last Year of Life* *To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual’s life expectancy is 6 months or less if the illness runs its normal course. Only care provided by (or under arrangements made by) a Medicare certified hospice is covered under the Medicare hospice benefit. The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician, nurse practitioner, physician assistant, and/or physician. NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf Spending is greater than Spending is less than non-hospice users non-hospice users No Difference / Not Statistically Significant • Hospice care saved Medicare approximately $3.5 billion for patients in their last year of life • Those patients with circulatory disease that had a hospice stay of even ≥ 2 weeks yielded a significant cost savings – For circulatory patients whose hospice stays were between 181-266 days, total cost of care was more than $5K less than non-hospice users – Circulatory patients with stays of > 266 days spent nearly $7K less than non-hospice users Disease Group No Hospice Hospice < 15 Days 15 – 30 31 – 60 61 – 90 91 – 180 181 – 266 > 266 ALL $67,192 4% -5% -9% -12% -14% -10% -12% Circulatory $66,041 7% -4% -8% -10% -11% -8% -10% Cancer $76,625 10% -1% -6% -9% -13% -14% -20% Neuro- degenerative $61,004 12% -6% -9% -11% -11% -5% -4% Respiratory $77,892 -2% -11% -14% -17% -19% -18% -22% CKD/ESRD $82,781 1% -14% -21% -24% -24% -23% -27%
  • 31. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content NORC’s Analysis Found That Hospice Spending for All Disease Groups is 11% Lower Compared to Non-hospice Users for Stays Exceeding 6 Months NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf
  • 32. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Comprehensive Services VITAS Palliative Care Home Health Eligibility Requirements Prognosis required: ≤ 6 months if the illness runs its usual course Prognosis varies by program, usually life-defining illness Prognosis not required Skilled need not required Skilled need not required Skilled need required Plan of Care Quality of life and defined goals Quality of life and defined goals Restorative care Length of Care Unlimited Variable Limited, with requirements Homebound Not required Not required Required, with exceptions Targeted Disease-Specific Program ✓ Variable Variable Medications Included ✓ X X Equipment Included ✓ X X After-Hours Staff Availability ✓ X X RT/PT/OT/Speech ✓ X ✓ Nurse Visit Frequency Unlimited Variable Limited, based on diagnosis Palliative Care Physician Support ✓ Variable X Levels of Care 4 1 1 Bereavement Support ✓ X X
  • 33. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • Unpredictable trajectory • Patient overestimates survival • Physicians overestimate survival • Frequent exacerbations • Hospitalized HF patient lacks DNR status • Patient misunderstands hospice • Physicians misunderstand hospice • Prognostication proves challenging • “Treatments are discontinued in hospice” Discomfort around EOL issues Communication breakdown Misinformation Patients’ and Clinicians’ Barriers to Hospice
  • 34. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Advanced interventions may be appropriate to palliate symptoms of ACD in hospice and must be discussed with the Hospice Medical Director prior to admission. • These may include: – Parenteral diuretics – IV inotropes – Pacemaker or cardiac resynchronization therapy (CRT) – Ventricular assist device (VAD) • A defibrillator is not palliative Advanced Cardiac Interventions in Hospice
  • 35. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • Diuretics can be administered IV or SQ • SQ diuretics can eliminate the need for an IV for patients at home • Similar outcomes between SQ and IV – Similar diuresis – No difference in rehospitalizations • Dosing can be continuous or intermittent infusion • Limited data in severely obese and end-stage kidney disease • Local side effects can occur: tingling, burning, swelling Advanced Interventions – Parenteral Diuretics Afari, et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review. Heart Failure Reviews, 24(3), 309-313.
  • 36. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Advanced Interventions – Inotropes Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616. IV inotropes may be used for palliation of symptoms in select patients with advanced HF who are not candidates for MCS or transplant • Improve NYHA Class (Functional Capacity) • No association with mortality or hospitalization • May increase risk of ICD shock Considerations for hospice: • Hospice may provide inotropes for palliation of symptoms • Cardiologist should be involved • Requires more permanent central venous access • Fixed dose, no up-titration • Patient/family agreeable to hospice plan of care (symptom- based, no cardiac monitor) • Typically admitted to hospice on continuous care
  • 37. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Advanced Interventions – Inotropes (cont.) Ginwalla, et al. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448. Name Mechanism of Action Primary Effects Maintenance Dose Benefits Risks/ Adverse Effects Significant Adverse Reaction Indications for Discontinuation Dobutamine Stimulates Beta-1 and Beta-2 receptors Inotropic and chronotropic 2-20 mcg/kg/min Slows heart rate and strengthens cardiac contractility Reduces sinoatrial firing rate Reduces atrial fibrillation and ventricular flutter Increases ejection fraction Decreases pulmonary congestion Tachycardia Dizziness Nausea and vomiting Anorexia Blurred vision Interacts with many meds and most OTC drugs •PVC’s •Palpitations •Headache •Nausea Side effects outweigh benefits Patient request (requires goals of care discussion) Refractory to inotrope/ Tolerance Develop HF symptoms Milrinone Phosphodiesterase III Inhibitor Inotropic, arterial and venous dilation 0.375-0.75 mcg/kg/min •Arrhythmias •Hypotension •Angina •Hypokalemia
  • 38. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Type Indication Benefits Burdens Comments/Reasoning Pacemakers/ CRTs Both: • Symptomatic bradycardia • 2○ or 3○ heart block CRT only: • NYHA Class III and IV • Certain Class II patients Improves: • Symptoms of heart disease • Quality of life • Cardiac function All: •Battery lifespan •Infection (rare) •Malfunction (rare) •Poorer outcomes1: –Typically placed in patients who are > 90 y/o, renal failure, active malignancy, connective tissue disorder, dementia cerebrovascular disease, AICD only: •Risk of traumatic death Life expectancy of years Rare to discontinue–may result in acute HF exacerbation Not palliative Recommend to deactivate when patient has advanced illness Defibrillators/ AICDs High risk of life-threatening arrhythmias Delivers shock to convert to normal rhythm Fewer hospitalizations VADs (LVAD, RVAD, BiVAD) Advancing HF despite maximal medical therapy– Bridge to transplant/ decision/recovery or destination therapy Improves: • HF symptoms • Quality of life Complications: • Stroke • Infection • Sepsis/pneumonia • Serious bleeds • Pump malfunction (rare) External battery must always be connected LVAD does not improve 1-yr survival but does show significant symptom benefit over OMM after 1 yr Improved survival with continuous flow2 : • 78% at 1 yr • 45% at 4 yrs Mechanical Interventions 1Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin. 2Balla, et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65:37-34.
  • 39. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content • Determine goals of care: what is important? • Manage symptoms holistically – Psychosocial interventions – Nonpharmacologic interventions – Medications • Avoid suffering and prolongation of dying • Achieve a sense of control • Relieve burdens • Strengthen relationship with loved ones The Role of Hospice in ACD
  • 40. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Trajectories After LVAD Implantation DeFilippis, et al. (2019). Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions. Journal of the American Geriatrics Society, 67(11), 2410–2419. https://doi.org/10.1111/jgs.16105 1 Preimplantation advanced care planning Inpatient support, symptom management Review of progress and goals of care, symptom management Triggered revisiting of goals of care Bereavement support 1 2 3 4 5
  • 41. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Caring for a patient with a VAD is fundamentally no different than caring for a patient without a VAD • Hospice team trained in VAD- specific symptom management, differences in physical exam, technical concerns • Hospice and cardiology teams collaborate closely • Address any patient and family concerns • Majority of VAD patients die with their VAD still functioning Elective discontinuation of VAD is a treatment option, decision made with treatment teams • Clinical indications for VAD deactivation – VAD failure or complications – Poor quality of life despite VAD – Advanced comorbid conditions • Can occur at home or inpatient unit – Clinical and psychosocial team involvement – Survival after deactivation ranges from minutes to days (average 20 minutes) VADs and Hospice
  • 42. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content In Summary • Heart Failure causes significant burden to patients and their caregivers, as well as the healthcare system • Patients with HF are generally eligible for hospice when they are mainly in bed or chair and have symptoms with less-than-normal activity • Hospice can help patients stay in their preferred setting by preventing hospitalizations • Hospice can prevent and alleviate suffering – physical, emotional, spiritual – with nonpharmacologic interventions, medications, and advanced interventions, for patients with advanced heart disease
  • 44. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Afari, et al. (2019). Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review. Heart failure reviews, 24(3), 309-313. Alghanem et al. (2020) Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care. Am J Emerg Med. 38(1), 89-94. Allen, L. A., et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952. American Heart Association. (2017). Cardiovascular disease: A costly burden for America projections through 2035. American Heart Association. (2020). Classes of Heart Failure. Retrieved from: https://www.heart.org/en/health-topics/ heart-failure/what-is-heart- failure/classes-of-heart-failure American Heart Association. (2022). 2022 Heart Disease and Stroke Statistics Update Fact Sheet At-a-Glance. Available at: https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2022-Heart-and-Stroke-Stat-Update/2022-Stat-Update- At-a-Glance.pdf Balla, C., et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65: 37- 43. Bekelman, D., et al. (2009). Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients. Journal of General Internal Medicine, 24(5), 592-598. Benjamin E., et al. (2019). Heart disease and stroke statistics: 2019 update. Circulation, 139(10):e56–528. Creber, et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378. DeFilippis, et al. (2019). Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions. Journal of the American Geriatrics Society, 67(11), 2410–2419. References
  • 45. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Ginwalla, et al. (2016). Home inotropes and other palliative care. Heart Failure Clinics, 12(3), 437-448. Ginwalla, et al. (2018). Current Status of Inotropes in Heart Failure. Heart Failure Clinics,14;601-616. Gotsman, et al. (2012). Heart failure and preserved left ventricular function: long term clinical outcome. PLoS One, 7(7), e41022. Harrington, et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin. Harrison, et al. (2022). Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life: Study examines hospice care quality for older adults with dementia in their last month of life. Health Affairs, 41(6), 821-830. Heidenreich, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology 79.17, e263-e421. Kheirbek, et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure. Circulation: Heart Failure, 8(4), 733-740. Khera, R., et al. (2020). Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States. British Medical Journal, 368:6831 Kitko, et al. on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. (2020). Family Caregiving for Individuals with Heart Failure. Circulation. 141: e864–e878. Kleinpell, et al. (2019). Exploring the association of hospice care on patient experience and outcomes of care. BMJ Supportive & Palliative Care, 9(1), e13-e13. References
  • 46. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432. Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal, 52.9, 659-679. MedPac July 2023 Report to the Congress: Medicare Payment Policy, Chart 11-23. Available at: https://www.medpac.gov/ document/july-2023-data-book-health-care-spending-and-the-medicare-program/ MedPac March 2023 Report to the Congress: Medicare Payment Policy, Table 10-3. Available at: https://www.medpac.gov/ document/march-2023-report-to-thecongress-medicare-payment-policy Mclluennan, et al. (2016). Palliative care in patients with heart failure. British Medical Journal, 6:352. National Alliance for Caregiving and AARP. Caregiving in the US 2020. NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/ wp-content/uploads/Value_Hospice_in_Medicare.pdf NHPCO. (2023). Facts and Figures: Hospice Care in America. Shah, et al. (2017) Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology. 70.20: 2476-2486 Tsao, et al. (2023) American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation. 2023 Feb 21;147(8):e93-e621. Wright, et al. (2010). Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health. Journal of Clinical Oncology, 28(29), 4457. References
  • 47. Advanced Cardiac Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content