Inotropic Medications for End-Stage Heart Disease

Describe your topic.: Among patients with end-stage heart disease on home hospice who require parenteral inotropic support, which protocols and/or types of inotropic medications confer the best outcomes related to patient quality of life, patient dyspnea score, patient pain score, patient fatigue, patient survival, caregiver burden, and/or caregiver quality of life?

Go AS, Mozaffarian D, Roger VL, et al. Heart Disease and Stroke Statistics--2013 Update: A report from the American Heart Association. Circulation 2013;217:e1-e240.
Teno JM, Gozalo PI, Bynum JPW, et al. Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care and Health Care Transitions in 2000, 2005, and 2009. JAMA 2013;309:470-7.
Malotte K, Saguros A, Groninger H. Continuous Cardiac Inotropes in Patients With End-Stage Heart Failure: An Evolving Experience. J Pain Symptom Manage 2018;55:159-63.
Chuang E, Kim G, Blank AE, Southern W, Fausto J. 30-Day Readmission Rates in Patients Admitted for Heart Failure Exacerbation with and without Palliative Care Consultation: A Retrospective Cohort Study. J Palliat Med 2016.
Francis GS, Bartos JA, Adatya S. Inotropes. Journal of the American College of Cardiology 2014;63:2069-78.

Describe why this topic is important.: Approximately 5.7 million Americans are living with heart failure and the prevalence of heart failure is projected to increase 46% by 2030.(1) In fact, the leading cause of death in the United States is heart disease. Most Americans prefer to spend the last weeks to months of their lives at home; however, repeated admissions near the end of life are common.(2) Home hospice care provides the highest standard of end of life care and aims to minimize burdensome transfers to the inpatient setting and to help patients realize the goal of remaining at home. Inotropes such as milrinone and dobutamine are increasingly used for patients with advanced heart failure to palliate symptoms when other advanced therapies such as left-ventricular assist devices or cardiac surgery are not options.(3) The availability of inotrope infusion in the home hospice setting is limited, however, due to high cost and the technical complexity and need for strong caregiver support in the home.(3) This may be a driver of increased readmissions for uncontrolled symptoms of advanced heart failure at the end of life.(4) There is little guidance on the relative benefits and burdens of types of inotropic medications and/or protocols for delivery in the palliative setting.(5) On the other hand, cost differences are significant.(3) In addition, questions around titrating inotrope dosing remain, and standard protocols are lacking.(3)

Tell us why you are suggesting this topic.: As Hospice and Palliative Medicine specialists, we recognize the challenges of providing optimal care for patients with advanced heart failure at the end of life. We hope that an evidence review of home inotrope infusions will help develop best practice policies for home hospice agencies, improve symptom management and reduce burdensome hospital transfers for patients at the end of life.

Lopez-Candales AL, Carron C, Schwartz J. Need for hospice and palliative care services in patients with end-stage heart failure treated with intermittent infusion of inotropes. Clinical cardiology 2004;27:23-8.

Describe what you are doing currently and what you are hoping will change because of a new evidence report.: At the present time, home inotrope support availability is limited for hospice patients with end-stage heart failure.(6) A rigorous evidence report may help develop policies that improve access to these therapies and potentially reduce suffering for patients with end-stage heart failure.

How will you or your group use the information from a new evidence report?: The American Academy of Hospice and Palliative Medicine will use the information from this new evidence report to inform guidelines for best practices for end of life care for end-stage heart failure patients.

How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?: The American Academy of Hospice and Palliative Medicine would disseminate this information to our members through newsletters and educational meetings. We would also disseminate this information to important stakeholders such including government and private payers of hospice care.

Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?: American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, The Hospice and Palliative Nurses Association, National Hospice and Palliative Care Organization

Information About You: (optional)

Provide a description of your role or perspective.: Hospice and palliative medicine physician-investigator

If you are you making a suggestion on behalf of an organization, please state the name of the organization.: American Academy of Hospice & Palliative Medicine

Please tell us how you heard about the Effective Health Care Program.: Email from AHRQ

Effective Health Care Program