A novel decision aid to help plan for serious illness: a multisite randomized trial.
A novel decision aid to help plan for serious illness: a multisite randomized trial.
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DOI：
10.9778/cmajo.20190179
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发表时间：
2020-04-01
期刊：
影响因子：
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通讯作者：
Howard, Michelle
中科院分区：
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作者：
Heyland, Daren K;Heyland, Rebecca;Howard, Michelle
背景技术背景：最近的研究表明，在严重疾病期间，沟通和决策的质量或数量（或两者）存在重大缺陷。我们评估了一种新的决策支持干预的有效性，计划好的指南，在增加完成一个标准的医疗订单形式的先进的医疗保健规划和改善决策结果在非学术的初级保健settings.METHODS：我们进行了一项随机试验，在3初级保健的做法在莱斯布里奇，阿尔伯塔在2017-2018年。我们招募了由初级保健医生转介的“高危患者”，这些患者需要建立或审查其护理目标指定（GCD）。入组的患者被随机分配接受由受过培训的促进者提供的计划良好指南或常规护理。干预后8 - 12周，一名对干预分配不知情的研究助理通过电话联系两组患者，进行最终结局评估。主要结果是完成GCD表格;次要结果包括决策冲突评分和满意度ratesofsatisfaction.RESULTS：共123例患者（59名女性[48.0%];平均年龄73.9岁），66名干预组和57名usualcare组; 119例患者完成了试验。干预后，干预组和常规护理组的GCD完成率分别为95.3%和90.9（风险差异[RD] 4%，95%置信区间[CI] -14%至22%），医嘱与随访偏好之间的一致率分别为78%和66（RD 12%，95% CI -7%至30%）。干预组中有重症监护室护理和心肺复苏书面医嘱的患者明显少于常规护理组（22例[34%] v. 33例[60%]，RD-26%，95% CI-42%至-8%）。干预组患者的决策冲突评分低于常规治疗组（平均值30.9 v. 43.1，校正平均差异-12.0，95%CI-23.2至-0.8）。医生认为干预组的患者比常规护理组的患者决策冲突更少，尽管差异不显著（平均评分10.4 v. 14.9，校正的平均差异-4.7，95% CI -9.9至0.4），与前者在一起的时间更少（平均9.7 v. 13.2 min，校正的平均差异-3.5，95%CI-5.5 to -1.5 min）.解释：决策支持干预并没有增加GCD完成率，但似乎确实改善了决策质量的某些方面，同时减少了医生完成GCD决策的时间。试验注册：ClinicalTrials.gov，编号NCT 01297946。
BACKGROUND: Recent studies have shown substantial deficiencies in the quality or quantity (or both) of communication and decision-making during serious illness. We evaluated the efficacy of a novel decision support intervention, the Plan Well Guide, in increasing completion of a standard medical order form for advance medical care planning and improving decisional outcomes in nonacademic primary care settings.METHODS: We conducted a randomized trial in 3 primary care practices in Lethbridge, Alberta in 2017-2018. We recruited "patients at high risk" referred by the primary care doctor who required establishment or review of their Goals of Care Designation (GCD). Enrolled patients were randomly allocated to receive the Plan Well Guide, delivered by a trained facilitator, or usual care. Eight to 12 weeks after the intervention, a research assistant blinded to intervention assignment contacted the patients in both groups by telephone to do a final outcome assessment. The primary outcome was completion of GCD forms; secondary outcomes included decisional conflict scores and ratings of satisfaction.RESULTS: A total of 123 patients (59 women [48.0%]; mean age 73.9 yr) were enrolled, 66 in the intervention arm and 57 in the usualcare arm; 119 patients completed the trial. After the intervention, GCD completion rates in the intervention and usual-care groups were 95.3% and 90.9%, respectively (risk difference [RD] 4%, 95% confidence interval [CI] -14% to 22%), and the rate of concordance between medical orders and expressed preferences on follow-up was 78% and 66%, respectively (RD 12%, 95% CI -7% to 30%). Significantly fewer patients in the intervention group than in the usual-care group had written medical orders for intensive care unit care and cardiopulmonary resuscitation (22 [34%] v. 33 [60%], RD -26%, 95% CI -42% to -8%). Patients in the intervention group had lower decisional conflict scores than those in the usual-care group (mean 30.9 v. 43.1, adjusted mean difference -12.0, 95% CI -23.2 to -0.8). Physicians considered patients in the intervention group to have lower decisional conflict than those in the usual-care group, although not significantly so (mean score 10.4 v. 14.9, adjusted mean difference -4.7, 95% CI -9.9 to 0.4) and spent less time with the former (mean 9.7 v. 13.2 min, adjusted mean difference -3.5, 95% CI -5.5 to -1.5 min).INTERPRETATION: The decision-support intervention did not increase GCD completion rates but did seem to improve some aspects of decisional quality while reducing the physician's time to accomplish GCD decisions. Trial registration: ClinicalTrials.gov, no. NCT01297946.