Use of Hospice and End-of-Life Care Quality Among Medical Centers with High Versus Lower Specialist Palliative Care Reach Among People with Heart Failure: An Observational Study.

Background: Rates of specialist palliative care (SPC) vary among Veterans Affairs Medical Centers (VAMCs) for people with advanced heart failure (aHF). We evaluated the associations between facility rates of SPC reach and the quality of end of life (EOL) care received among this population. Methods: We conducted a retrospective cohort study among 3681 people with aHF who died in 83 VAMCs from 2018 to 2020. We used multilevel logistic regression to derive SPC reach (i.e., the predicted probability or rate of SPC) for each VAMC adjusting for demographic and clinical characteristics. We examined the associations between high (top 20%) versus lower (bottom 80%) SPC reach and receipt of inpatient hospice and family-reported EOL care quality and the interactions between receiving SPC and VAMC reach on study outcomes. Results: The sample included 97.9% male, 61.6% White, and 32.2% Black adults (mean age = 72.9 ± 10.9 years). Rates of "Excellent" EOL care quality, but not inpatient hospice care, were significantly higher in VAMCs in the top 20% of reach (predicted probability: inpatient hospice = 0.56 vs. 0.51, p = 0.32; "Excellent" EOL care quality 0.69 vs. 0.60, p = 0.04). There was a significant interaction between VAMC reach, receipt of SPC, and inpatient hospice (p < 0.001) but no interaction between VAMC reach, receipt of SPC, and EOL care quality (p = 0.049). Conclusion: Families of patients with aHF who die in VAMCs with higher SPC reach report better EOL care quality regardless of whether or not they receive SPC. Research is needed to investigate factors beyond receiving SPC associated with these EOL outcomes.