Regional Variations in the Provision of Palliative Care in Patients Hospitalized with Heart Failure within the Veterans Health Administration (S730)

Abstract: Objectives: Describe a method for identifying high and low performing geographical regions in terms of palliative care use within the Veterans Health Administration. Identify associations between the Veterans Health Administration's 18 service delivery networks, Veterans Integrated Service Networks regions and palliative use among patients hospitalized with heart failure. Original Research Background: Palliative care (PC) use is increasing among hospitalized heart failure (HF) patients. The Veterans Health Administration (VHA) was an early adopter of PC, with services offered in all inpatient facilities. Research Objectives: To identify regional differences in PC use and determine associations between region and PC in hospitalized HF patients in the VHA. Methods: We conducted a nested case-control study of patients with HF who were hospitalized from fiscal years 2003–2015 enrolled in the Veterans Aging Cohort Study (VACS), a study of HIV-infected and uninfected adults. PC was identified using ICD-9 code V66.7. Cases with PC (n = 210) were matched 1:5 to 1,042 HF patients without the PC code by age, hospital discharge date, and ejection fraction. We categorized regions by the VHA’s 18 service delivery networks, Veterans Integrated Service Networks (VISNs). We calculated the ratio of PC cases to controls for each VISN. VISNs within the top 25% of VISN ratios were defined as high performers and the bottom 25% as low performers. We conducted conditional logistic regression to determine associations between VISN and covariates including the VACS Index (prognostic indicator), HIV infection, comorbidities, hospitalization characteristics, and PC. Results: The sample was 99% male, the mean age was 64±10 years and 54% of cases and 57% of controls were African American. Controlling for hospital length of stay, the VACS Index, and HIV infection, patients hospitalized in high performing VISNs had 4.46 times the odds (95% Confidence Interval [CI] 2.60 – 7.62) of PC compared to low performing VISNs. Conclusion: Significant regional variation exists among PC utilization for patients hospitalized with HF within the VHA.