P3HF study protocol details pragmatic RCT to boost palliative care for hospitalized heart failure patients

Despite strong clinical guidelines recommending palliative care for heart failure (HF), fewer than 20% of patients receive it, leading to high symptom burden, frequent hospitalizations, and significant end-of-life suffering. This gap highlights a critical need for interventions that promote timely access to palliative services. The P3HF Clinical Decision Support (CDS) tool was developed to address this, integrating a validated prognostic-risk model and behavioral nudges directly within the electronic health record (EHR) to facilitate appropriate referrals.

This manuscript describes the protocol for a pragmatic randomized clinical trial (RCT) designed to evaluate the P3HF CDS tool. The trial will be conducted at two large urban hospitals within a single health system, employing an embedded, convergent mixed-methods design. Eligible patients are adults (≥ 18 years) hospitalized with heart failure, an N-terminal pro-B-type natriuretic peptide (NT-proBNP) level ≥ 500 pg/mL, and receipt of intravenous diuretics within 24 hours of admission. The study will analyze data from the EHR, alongside surveys and interviews with end-users (attending physicians, residents, fellows, advanced practice providers) and palliative care clinicians, to assess various outcomes.

As a study protocol, this paper details the objectives of the upcoming P3HF trial rather than presenting findings. The primary clinical outcome that the trial will evaluate is an increase in inpatient palliative care consultations. Secondary exploratory outcomes include increasing palliative care outpatient referrals, improved advance care planning documentation, higher hospice enrollment, and reductions in hospital length of stay and 30-day readmissions when compared to usual care. Additionally, the mixed-methods approach will assess implementation outcomes such as the usability, acceptability, appropriateness, and feasibility of the P3HF CDS tool among end-users. The trial aims to provide robust evidence on the effectiveness of an EHR-integrated CDS in promoting timely palliative care for heart failure patients.