Improving Advance Care Planning in Oncology: A Pragmatic, Cluster-Randomized Trial Integrating Patient Videos and Clinician Communication Training

项目摘要/摘要 每年有太多患有晚期癌症的老年美国人在接受积极干预后死亡 不能反映他们的价值观、目标和喜好的生活。高级护理计划(ACP)是最重要的 一致的可修改因素与更好的临终沟通和目标一致的护理相关。 然而，临床医生通常不具备高质量的ACP对话所需的沟通技能 患者往往无法想象自己的医疗选择，从而做出明智的决定。致信地址 为了弥补这一差距，我们制定了一项全面的机场核心计划，该计划结合了两个经过充分测试的证据- 基于和补充的干预措施：临床医生沟通技能培训和患者视频决策 爱滋病。这种包容性的ACP方法将患者和临床医生视为平等的利益相关者，为两者提供 在最艰难的选择出现之前，以最佳方式做出明智决策所需的沟通技能和工具。 我们已经在几个小范围内展示了全面ACP干预要素的有效性 老年癌症患者的随机对照试验。这项提案的总体目标是进行一项 在三个大型医疗保健系统中的务实阶梯式楔形群随机试验(SW-CRT)：Duke Health， 梅奥诊所和诺斯韦尔健康中心。在UG3的第一年，我们将建立组织、流程、 和基础设施，以制定一个务实的方方面面的软件-CRT的干预为4,500 65岁以上的晚期癌症患者，并在每个系统的一个肿瘤科诊所试行研究方案 (目标1)。在UH3阶段的四年期间，我们将在三个肿瘤科诊所的36个肿瘤科诊所进行西南-CRT 系统，并通过比较以下结果来评估干预的有效性：1.推进 护理计划完成情况；2.复苏偏好医嘱；3.姑息护理咨询；4. 临终关怀用途(目标2)。我们将在每个健康系统使用已建立的电子健康记录系统，以获得 结果。我们假设，在干预阶段(与对照组相比)有更高比例的患者将： 完整的先期护理计划(主要试验结果)，已记录以下电子医疗订单 复苏偏好，在姑息治疗咨询中被看到，并登记在临终关怀。我们还将 在450名患者中描述以患者为中心的详细结果，包括视频声明 个人偏好(目标3)。临床医生沟通培训和视频决策支持是一项 实用、以证据为基础的创新方法，统一提供强大的机场核心计划。这部作品具有 有可能改善向数百万患有癌症的老年美国人提供的护理质量。

Project Summary/Abstract Too many older Americans with advanced cancer die every year receiving aggressive interventions at the end of life that do not reflect their values, goals, and preferences. Advance Care Planning (ACP) is the most consistent modifiable factor associated with better end-of-life communication and goal-concordant care. However, clinicians often do not possess the communication skills needed for high-quality ACP conversations and patients are often unable to imagine their options for medical care to make informed decisions. To address this gap, we have developed a Comprehensive ACP Program that combines two well-tested, evidence- based, and complementary interventions: clinician communication skills training and patient video decision aids. This inclusive ACP approach treats patients and clinicians as equal stakeholders providing both with the communication skills and tools needed to optimally make informed decisions before the toughest choices arise. We have shown the efficacy of the elements of the Comprehensive ACP intervention in several small randomized controlled trials for older patients with cancer. The overall objective of this proposal is to conduct a pragmatic stepped wedge cluster randomized trial (SW-CRT) in three large health care systems: Duke Health, the Mayo Clinic, and Northwell Health. During the first UG3 year, we will establish the organization, processes, and infrastructure necessary to develop all aspects of a pragmatic SW-CRT of the intervention for 4,500 patients over 65 with advanced cancer and pilot test the study protocol in one oncology clinic in each system (Aim 1). During the four years of the UH3 stage, we will conduct a SW-CRT in 36 oncology clinics in the three systems and evaluate the effectiveness of the intervention by comparing the following outcomes: 1. Advance care plans completion; 2. Medical orders for resuscitation preferences; 3. Palliative care consultations; and 4. Hospice use (Aim 2). We will use established electronic health record systems at each health system to obtain outcomes. We hypothesize that a higher proportion of patients in the intervention phase (vs. control) will: complete advance care plans (primary trial outcome), have documented electronic medical orders for resuscitation preferences, be seen in palliative care consultations, and enroll in hospice. We will also characterize detailed patient-centered outcomes in a subgroup of 450 patients, including video declarations of individual preferences (Aim 3). Clinician communication training along with video decision support is a practical, evidence-based, and innovative approach to uniformly provide robust ACP. This work has the potential to improve the quality of care provided to millions of older Americans with cancer.