Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) together affect up to 25% of Veterans. Despite disease-specific medical care for CHF and COPD, Veterans with either illness are often left with poor quality of life (i.e., burdensome symptoms, impaired function). Quality of life is reduced for similar reasons in both illnesses, particularly from the burden of significant residual symptoms such as shortness of breath and fatigue and other concurrent symptoms such as pain and depression. Furthermore, while CHF and COPD are leading causes of hospitalization and mortality, few Veterans with either illness engage in advance care planning, the process of considering and communicating healthcare values and goals. While palliative care is often thought of only at the end of life, it has great potential t improve quality of life and advance care planning for Veterans earlier in illness, concomitant with ongoing medical management. Our preliminary studies demonstrate early success with a Veteran-centered palliative care intervention in CHF and COPD. The palliative care intervention, Collaborative care to Alleviate Symptoms and Adjust to illness (CASA) consists of the following components: (1) algorithm-guided management of breathlessness, fatigue, and pain, provided by a nurse; the algorithms supplement disease-focused treatments with palliative and behavioral treatments; (2) a 6-session psychosocial care program targeting adjustment to illness and depression, provided by a social worker; and (3) engagement of patients and providers in advance care planning. We propose conducting a hybrid effectiveness and implementation study to further evaluate the CASA intervention. Population-based sampling methods will be used to enroll 300 Veterans with CHF or COPD who have poor quality of life and are at risk for hospitalization or death. The primary aim is to test the effectiveness of CASA in a randomized controlled trial (intervention vs. enhanced usual care) in two VA health care systems. We will determine the effect of the CASA intervention on (a) quality of life as a primary outcome, and (b) disease-specific health status, depression, symptom burden, advance care planning communication and documentation, emergency department visits, hospitalizations, and mortality as secondary outcomes. In a secondary aim in this study, we will use a combination of qualitative and quantitative methods to examine the implementation of the intervention. Information on implementation is rarely collected systematically in effectiveness studies, even though it is critical to guide the development of future interventions and for successful implementation and dissemination of palliative care and team-based interventions. The information gained from this aim will inform future palliative care and team-based interventions as well as ways to expand the reach of palliative care. The proposed study is significant because it aims to improve quality of life and provision of care according to Veterans' goals and preferences in common, burdensome illnesses. The study is innovative because it (1) tests the effectiveness of palliative care in CHF and COPD, leading causes of death among Veterans; (2) combines palliative and disease-specific care for symptoms with psychosocial treatment for depression to improve quality of life; and (3) leverages the skills of affiliate health providers (nurses, social workers) to provide basic palliative care, with physician supervision; and (4) uses an hybrid effectiveness/implementation design to increase the relevance to operations leaders and future research. The research team has expertise in behavioral and health care delivery clinical trials, CHF and COPD, and implementation science.
Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) together are leading causes of disability, hospitalizations, death, and costs in the VA. Veterans who live with either illness suffer from numerous symptoms that affect their daily lives despite medical care for these illnesses. We will conduct a study to determine whether an intervention to improve symptoms and to help Veterans adjust to living with CHF and COPD improves quality of life. The intervention will also help Veterans communicate preferences for treatment with their providers. The results will be directly relevant to Veterans who suffer with these illnesses and their families, as well as to providers, leaders in VA Central Office, and other researchers. Furthermore, this study will generate information that supports the broader dissemination and implementation of the intervention and informs the development of future palliative care and team-based interventions in the VA.
