RPD104 - Clinician Staffing, Palliative Uptake, and End-of-Life Care in Heart Failure in Veterans Affairs Medical Centers.

Key Message : In this study of people with heart failure in the Department of Veterans Affairs, staffing models with balanced full-time equivalents (FTE; i.e., physician/ advanced practice provider/social worker/psychologist) had 5% higher rates of palliative uptake relative to models with high-physician FTE. Targeted palliative staffing may impact specific outcomes, warranting further research.

Abstract:

Background: Palliative care is a guideline-concordant intervention in heart failure (HF)(1), but the optimal palliative care team staffing associated with high palliative uptake and end-of-life-care quality among this population remains unknown.

Objectives: To describe the association between palliative care staffing, palliative uptake, and end-of-life care quality outcomes in HF in Department of Veterans Affairs Medical Centers (VAMCs).

Methods: We conducted a secondary analysis of HEART-PAL Cohort data, examining palliative care uptake, defined as the proportion of people with HF receiving palliative care, days at home in the last 90 days of life, and hospice enrollment in the final three and seven days of life. Outcomes were adjusted for patient demographic and clinical characteristics. We calculated clinician staffing ratios for each VAMC from full-time equivalents (FTE) data from 2022-2023. Ratios were expressed as the fraction of FTE of a specific subgroup of FTE (i.e., physician, advanced practice provider (APP), social worker/psychologist) to all clinician FTE*1000. We identified palliative care staffing models using a k-means clustering approach(2) and generalized estimating equations to determine associations between staffing models and outcomes. High physician FTE was the referent, and models controlled for VAMC characteristics.

Results: The analysis of 113 VAMCs comprising 24,041 patients (98% male) identified 4 palliative clinician staffing models: balanced (33, 29%), high APP (20, 18%), high physician (36, 32 %), and high social worker/psychologist (20, 21%). Balanced team FTE was associated with a 5% higher rate of palliative uptake relative to the high physician FTE model (95% Confidence Interval 0.001-0.09; p = 0.04). There were no significant differences among staffing models and other outcomes.

Conclusion: Targeted palliative staffing strategies may be associated with palliative and end-of-life care quality outcomes. Findings underscore the potential importance of strategic staffing in promoting palliative and end-of-life care quality in HF, highlighting opportunities for further research.

References: 1. Writing Committee Members; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Card Fail. 2022;28(5):e1-e167. doi:10.1016/j.cardfail.2022.02.010.
2. Sun QW, Forman HP, Stern L, Oldfield BJ. Clinician Staffing and Quality of Care in US Health Centers. JAMA Network Open. 2024;7(10):e2440140-e2440140. doi:10.1001/jamanetworkopen.2024.40140.