Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents A Pragmatic Cluster Randomized Clinical Trial
Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents A Pragmatic Cluster Randomized Clinical Trial
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DOI：
10.1001/jamainternmed.2020.2366
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发表时间：
2020-08-01
影响因子：
39
通讯作者：
Mor, Vincent
中科院分区：
文献类型：
--
作者：
Mitchell, Susan L.;Volandes, Angelo E.;Mor, Vincent
重要性标准化的，以证据为基础的方法进行提前护理计划（ACP）在nursinghomes.OBJECTIVE测试的效果ACP视频程序对医院的转移，繁重的治疗，并在长期居住的养老院居民与非晚期疾病的临终关怀登记。疗养院视频教育的实用性试验是一项实用的随机分组临床试验，于2016年2月1日至5月31日进行，2019年，在32个州的360家养老院（119家干预和241家控制），由2家营利性公司拥有。参与者包括干预组4171名患有晚期痴呆或心肺疾病（以下简称晚期疾病）的长期居民和对照组8308名患有晚期疾病的长期居民，干预组5764名没有晚期疾病的长期居民和对照组11773名没有晚期疾病的长期居民。干预5个6- 10分钟的ACP视频可在平板电脑或网上获得。干预设施中的指定冠军（主要是社会工作者）被指示为居民（或其代理人）提供在入院时和每6个月观看视频的机会。控制设施使用通常的ACP practices.Main结果和措施测量每个居民的12个月的结果。主要结局是晚期疾病队列中每1000人日存活的医院转院次数。次要结果包括有或无晚期疾病的居民经历1次或多次医院转移，1次或多次负担性治疗和临终关怀登记的比例。为了监测忠诚度，冠军在电子记录中完成报告，每当他们提供给居民看一个视频。结果这项研究包括4171名长期居住的居民与先进的疾病在干预组（2970名女性[71.2%];平均[SD]年龄为83.6 [9.1]岁），对照组为8308名晚期疾病的长期住院患者（5857名女性[70.5%];平均[SD]年龄，83.6 [8.9]岁），干预组中5764名无晚期疾病的长期住院居民（3692名女性[64.1%];平均[SD]年龄，81.5 [9.2]岁），对照组中有11773名长期居住的居民，无晚期疾病（7467名女性[63.4%];平均[SD]年龄，81.3 [9.2]岁）。与对照组相比，干预组每1000人-天的住院转移率没有显著降低（率[SE]，3.7 [0.2]; 95% CI，3.4-4.0 vs 3.9 [0.3]; 95% CI，3.6-4.1;率差[SE]，-0.2 [0.3]; 95% CI，-0.5至0.2）。在有和没有晚期疾病的居民中，试验组之间的次要结局没有显著差异。根据冠军的报告，4171名患有晚期疾病的居民中有912人（21.9%）观看了ACP视频。显示ACP视频的设施级比率范围从0%（119个设施中的14个[11.8%]）到超过40%（22个设施[18.5%]）。结论和相关性本研究发现，ACP视频程序在减少医院转移，减少繁重的治疗使用，或增加临终关怀的长期住院患者中有或没有晚期疾病的登记率方面是无效的。干预保真度低，突出了在养老院实施新计划的挑战。
IMPORTANCE Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking.OBJECTIVE To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness.DESIGN, SETTING, AND PARTICIPANTS The Pragmatic Trial of Video Education in Nursing Homes was a pragmatic cluster randomized clinical trial conducted between February 1, 2016, and May 31, 2019, at 360 nursing homes (119 intervention and 241 control) in 32 states owned by 2 for-profit corporations. Participants included 4171 long-stay residents with advanced dementia or cardiopulmonary disease (hereafter referred to as advanced illness) in the intervention group and 8308 long-stay residents with advanced illness in the control group, 5764 long-stay residents without advanced illness in the intervention group, and 11 773 long-stay residents without advanced illness in the control group. Analyses followed the intention-to-treat principle.INTERVENTIONS Five 6- to 10-minute ACP videos were made available on tablet computers or online. Designated champions (mostly social workers) in intervention facilities were instructed to offer residents (or their proxies) the opportunity to view a video(s) on admission and every 6 months. Control facilities used usual ACP practices.MAIN OUTCOMES AND MEASURES Twelve-month outcomeswere measured for each resident. The primary outcome was hospital transfers per 1000 person-days alive in the advanced illness cohort. Secondary outcomes included the proportion of residents with or without advanced illness experiencing 1 or more hospital transfer, 1 or more burdensome treatment, and hospice enrollment. To monitor fidelity, champions completed reports in the electronic record whenever they offered to show residents a video.RESULTS The study included 4171 long-stay residents with advanced illness in the intervention group (2970 women [71.2%]; mean [SD] age, 83.6 [9.1] years), and 8308 long-stay residents with advanced illness in the control group (5857 women [70.5%]; mean [SD] age, 83.6 [8.9] years), 5764 long-stay residents without advanced illness in the intervention group (3692 women [64.1%]; mean [SD] age, 81.5 [9.2] years), and 11 773 long-stay residents without advanced illness in the control group (7467 women [63.4%]; mean [SD] age, 81.3 [9.2] years). There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention vs control groups (rate [SE], 3.7 [0.2]; 95% CI, 3.4-4.0 vs 3.9 [0.3]; 95% CI, 3.6-4.1; rate difference [SE], -0.2 [0.3]; 95% CI, -0.5 to 0.2). Secondary outcomes did not significantly differ between trial groups among residents with and without advanced illness. Based on champions' reports, 912 of 4171 residents with advanced illness (21.9%) viewed ACP videos. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities [11.8%]) to more than 40% (22 facilities [18.5%]).CONCLUSIONS AND RELEVANCE This study found that an ACP video program was not effective in reducing hospital transfers, decreasing burdensome treatment use, or increasing hospice enrollment among long-stay residents with or without advanced illness. Intervention fidelity was low, highlighting the challenges of implementing new programs in nursing homes.