In the JournalsPerspective

CASA: Collaborative intervention improves fatigue, depression in HF

Patients with symptomatic HF and reduced health status who were treated with a collaborative care intervention had improvements in fatigue and depression, but did not attain an improved HF-specific health status, according to a study published in JAMA Internal Medicine.

David B. Bekelman, MD, MPH, of the Department of Veterans Affairs, Eastern Colorado Health Care System in Denver, and colleagues conducted the CASA trial, an NIH-funded single-blind, two-arm, randomized clinical trial with 314 patients with chronic HF and reduced health status from three health systems.

Patients were randomly assigned collaborative care to alleviate symptoms and adjust to illness (n = 157; mean age, 65 years; 82% men) or usual care (n = 157; mean age, 67 years; 76% men). Collaborative care included a registered nurse addressing symptoms, a social worker providing structured psychosocial care and a team that reviewed the patient’s care and provided orders for tests. Patients in the usual care group received care from palliative care, cardiology and mental health at the clinicians’ discretion.

The primary outcome was patient-reported HF-specific health status at 6 months using the Kansas City Cardiomyopathy Questionnaire. Secondary outcomes included anxiety, depression, overall symptom distress, mortality, number of hospitalizations and specific symptoms such as shortness of breath, fatigue and pain.

HF with reduced ejection fraction was seen in 56.7% of patients.

At 6 months, the Kansas City Cardiomyopathy Questionnaire improved by 5.5 points in the intervention group and 2.9 points in the control group (difference, 2.6; 95% CI, –1.3 to 6.6).

Improvements at 6 months were also seen in fatigue (effect size, –0.3; 95% CI, –0.55 to –0.06) and depressive symptoms (effect size, –0.29; 95% CI, –0.53 to –0.04) in patients assigned the intervention. Significant changes were not seen in the number of hospitalizations, pain, symptom distress and shortness of breath.

At 12 months, mortality was similar in the intervention and control groups (10 vs. 13, respectively; P = .52).

“The next steps in research could include (1) testing intervention components on specific outcomes (eg, psychosocial care intervention for patients with depressive disorder or fatigue); (2) studying the intervention in a higher-risk or more ill population, as another study using specialist palliative care has done, or an underserved or rural population; and (3) using health information technology (eg, videoconference) to increase the reach, intensity or scalability of the intervention,” Bekelman and colleagues wrote. “It is possible that further refinement of the intervention could improve disease-specific health status.” – by Darlene Dobkowski

Disclosures: The authors report no relevant financial disclosures.

Patients with symptomatic HF and reduced health status who were treated with a collaborative care intervention had improvements in fatigue and depression, but did not attain an improved HF-specific health status, according to a study published in JAMA Internal Medicine.

David B. Bekelman, MD, MPH, of the Department of Veterans Affairs, Eastern Colorado Health Care System in Denver, and colleagues conducted the CASA trial, an NIH-funded single-blind, two-arm, randomized clinical trial with 314 patients with chronic HF and reduced health status from three health systems.

Patients were randomly assigned collaborative care to alleviate symptoms and adjust to illness (n = 157; mean age, 65 years; 82% men) or usual care (n = 157; mean age, 67 years; 76% men). Collaborative care included a registered nurse addressing symptoms, a social worker providing structured psychosocial care and a team that reviewed the patient’s care and provided orders for tests. Patients in the usual care group received care from palliative care, cardiology and mental health at the clinicians’ discretion.

The primary outcome was patient-reported HF-specific health status at 6 months using the Kansas City Cardiomyopathy Questionnaire. Secondary outcomes included anxiety, depression, overall symptom distress, mortality, number of hospitalizations and specific symptoms such as shortness of breath, fatigue and pain.

HF with reduced ejection fraction was seen in 56.7% of patients.

At 6 months, the Kansas City Cardiomyopathy Questionnaire improved by 5.5 points in the intervention group and 2.9 points in the control group (difference, 2.6; 95% CI, –1.3 to 6.6).

Improvements at 6 months were also seen in fatigue (effect size, –0.3; 95% CI, –0.55 to –0.06) and depressive symptoms (effect size, –0.29; 95% CI, –0.53 to –0.04) in patients assigned the intervention. Significant changes were not seen in the number of hospitalizations, pain, symptom distress and shortness of breath.

At 12 months, mortality was similar in the intervention and control groups (10 vs. 13, respectively; P = .52).

“The next steps in research could include (1) testing intervention components on specific outcomes (eg, psychosocial care intervention for patients with depressive disorder or fatigue); (2) studying the intervention in a higher-risk or more ill population, as another study using specialist palliative care has done, or an underserved or rural population; and (3) using health information technology (eg, videoconference) to increase the reach, intensity or scalability of the intervention,” Bekelman and colleagues wrote. “It is possible that further refinement of the intervention could improve disease-specific health status.” – by Darlene Dobkowski

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Eric D. Adler

    Eric D. Adler

    The paper reaffirms some of the challenges that we face in treating patients with advanced HF. It does show that a multifaceted holistic approach can improve some of the most stubborn and impactful symptoms of HF (depression and fatigue). This is relevant, as these two symptoms have an outsized impact on quality of life and have been particularly resistant to other interventions.

    It will impact how we allocate resources to treat these patients. It may serve as a reality check. It is probably not realistic to expect an intervention like this to impact mortality.

    I would like to see similar research that focuses on both the patient and the caregiver of patients who have significant burden and stress. A structured study on the impact of a cardiologist on these patients would also be of interest. Many of these patients were not seen by cardiologists.

    These negative studies should not dissuade further well-controlled studies of similar interventions in this patient population.

    • Eric D. Adler, MD
    • Director, Cardiac Transplant and Mechanical Circulatory Support Associate Professor of Medicine University of California, San Diego

    Disclosures: Adler reports no relevant financial disclosures.