1. Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA), a collaborative care intervention combining symptom and psychosocial care, did not improve heart failure-specific health status in chronic heart disease, compared to usual care.
2. When compared to usual care, CASA did improve secondary outcomes of depression and fatigue.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Patients with heart failure experience significant morbidity from symptoms such as breathlessness, fatigue, pain, and depression. Though palliative care is recommended for heart failure patients, the availability of palliative care specialists for the large population of heart failure patients is limited, and interventions that can be integrated earlier and are scalable to a large number of patients are greatly needed. This study assessed the potential benefits of the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) intervention, which uses nurses and social workers to apply palliative care approaches to treat symptoms and psychosocial care to treat depression. The authors found that compared to usual care, CASA did not differ in improving the Kansas City Cardiomyopathy Questionnaire (KCCQ) score, a measure of heart failure-specific health status. However, the depressive symptoms did improve with CASA over usual care, and there was a temporary improvement in both fatigue and anxiety.
This trial was the first to assess a palliative and psychosocial collaborative care intervention for heart failure patients, and was both randomized and consisted of a large number of patients from a diverse background and health systems. However, it is possible that the sample was not representative of and cannot be generalized to all heart failure patients, and that there was not sufficient power to detect a modest intervention effect.
Relevant Reading: Defining the role of palliative care in older adults with heart failure.
In-Depth [randomized controlled trial]: This study examined a sample of 314 heart failure patients in 3 health systems (urban safety net, Veterans Affairs, and academically affiliated health systems) identified via electronic health records, and randomized them to receive the CASA intervention or usual care. The CASA intervention included (1) a registered nurse to address symptoms, (2) a social worker to provide structured psychosocial care, and (3) a team including physicians, who reviewed the patient’s care and provided guidance on tests and medications to the patients’ clinicians. On the other hand, usual care involved care at the discretion of their clinicians.
Patients who received CASA did not differ significantly from patients receiving usual care in terms of the KCCQ health status score (score improvement of 5.5 vs. 2.9 points in the CASA and usual care arms, respectively; difference, 2.6; 95% CI, -1.3 to 6.6; p = 0.19). However, depressive symptoms did improve with CASA (effect size of -0.34 at 3 months with p = 0.01; -0.29 at 6 months with p = 0.02). Fatigue and anxiety also improved but did not persist at 12 months. Mortality was similar in both arms (10 of 157 in CASA arm, 13 of 157 in usual care arm, p = 0.52).
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