DFM-led study shows coordinated primary, palliative, specialty care improve outcomes for organ failure patients at end of life

Patients with heart failure who had palliative care involvement in their last year of life had lower rates of hospitalization and acute care deaths compared to those without, but only about a third of those patients receive palliative care, according to a new study from ICES, McMaster University, Bruyère Health Research Institute, and University of Ottawa.

As people live longer with progressive life-limiting illnesses, care is often managed by multiple providers and specialists as individuals approach the end of life. Specialists are essential to addressing disease-specific issues, but the involvement of various providers may lead to fragmentation in care, disrupting continuity of care and its benefits.

“Our findings support the scaling of integrated care models which emphasize collaboration between specialist, primary, and palliative care providers,” said senior author Michelle Howard, an adjunct scientist with ICES and an associate professor in the Department of Family Medicine at McMaster. The paper is the third in a series, with recent studies exploring care patterns for patients with advanced chronic obstructive pulmonary disease (COPD) and kidney failure.

The study included 65,625 patients who died of heart failure across Ontario between 2017 and 2019. Researchers found that only 44% of individuals who had palliative and primary care and 55% of individuals who had palliative, primary, and specialist care died in acute care, compared to 74% of individuals who had primary and specialist care, but no palliative care.

Individuals receiving just primary and palliative care also spent the least number of days in hospital or the emergency department in the last 30 days of life, compared to individuals who were receiving a different combination of care.

“Patients with serious chronic diseases rely on primary care providers throughout their final year,” said Howard. “Continuous primary care involvement provides valuable continuity that supports management of medical complexities, attention to comorbidities, and coordination of specialized services for patients.”

The study indicated that most outpatient care for people dying with heart failure was provided by primary care physicians throughout the last year of life, with increased palliative care physician involvement as patients approached death.

“This isn’t the first time we see how sustained palliative care reduces hospitalizations and deaths in hospital toward the end of life,” said Sarina Isenberg, Chair in Mixed Methods Palliative Care Research at Bruyère Health Research Institute, associate professor at the University of Ottawa, and adjunct scientist with ICES. “In multiple disease populations we are seeing that less than half of patients are receiving palliative care in the last year of life, suggesting we need to improve access to palliative services and initiate services earlier.”

Across patients with heart failure, advanced COPD, and kidney failure, those who received coordinated primary, palliative, and specialty care had lower acute care use and fewer hospital deaths, highlighting the critical role of integrated outpatient care in enhancing quality of life at end of life.