Effectiveness of Engaging in Advance Care Planning Talks (ENACT) Group Visits Intervention in Primary Care for Older Adults with and without Alzheimer's Dementia

项目摘要 患有阿尔茨海默病和相关痴呆症（ADRD）的个体可能会经历不必要的， 密集或繁重的临终关怀，因为他们的医疗保健不知道他们对护理的偏好， 决策者。例如，近41%的ADRD患者至少接受了一次强化治疗。 干预（例如，在生命的最后3个月内进行机械通气，人工营养），这可能会延长生命 但没有解决生活质量问题。因此，及时讨论提前护理计划（ACP）是 在痴呆症患者失去决策能力之前，这是至关重要的。有认知障碍的人， 从轻度认知障碍到痴呆症，通常在初级保健中得到照顾。但小学 护理机构没有有效的模式，可以系统地整合临床医生-患者的讨论， 有认知障碍和无认知障碍的老年人对ACP的决策， 制作能力。为了解决这些差距，我们设计了，并根据利益相关者的意见进行了改进， 基于理论和实践的ACP组访视干预的可行性、可接受性和有效性 老年初级保健患者的团体访问（参与预先护理计划会谈）。ENACT集团 访问是两次促进讨论，间隔一个月，由医生或高级实践提供者和 社工干预使用基于证据的ACP材料，并利用团体动态， 促进患者的目标设定和自我效能。在一项单诊所试点研究中，随机接受ENACT的患者 6个月时，与对照组相比，小组访视干预组的ACP文件率高出26%。 邮寄ACP材料（p=0.007）。本研究旨在测试ENACT团体访问的有效性，以增加 ACP记录（ACP的一个方面），并评价其在各种患者中的有效性 包括早期痴呆症。拟定的2组、患者水平随机试验将 在五个初级保健诊所进行，并有能力比较ENACT组访视干预与对照 邮寄ACP材料。我们将按照存在或不存在使用1：1分配和患者水平区组随机化 的CI。该研究将使用ACEE ™的组成部分，这是一项以证据为基础的ACP计划，旨在减少 认知负担和易于阅读的预先指示。目标1将决定《国家打击贩运人口法》的有效性 6个月时的组访视与对照组相比，以增加ACP记录（主要结局），ACP准备， 决策自我效能和沟通质量（次要结果）。目标2将决定 ENACT小组访视干预的有效性因认知障碍而异，包括ADRD。目标3将 描述ENACT的可接受性和可行性，以及干预保真度和实施结果 采用定性和混合方法进行小组访问干预。这项基于初级保健的有效性试验， ENACT小组对老年人（包括痴呆症患者）的访问干预将产生所需的 将有效的ACP干预措施实施到实际初级保健环境中的证据。

PROJECT SUMMARY Individuals living with Alzheimer's Disease and Related dementias (ADRD) may experience unwanted, intensive or burdensome end-of-life care because their preferences for care are unknown to their medical decision makers. For example, nearly 41% of individuals with ADRD undergo at least one intensive intervention (e.g., mechanical ventilation, artificial nutrition) in the last 3 months of life, which may prolong life but does not address quality of life. Thus, timely discussions about advance care planning (ACP) are imperative before individuals with dementia lose decision making capacity. Persons with cognitive impairment, spanning from mild cognitive impairment to dementia, are often cared for in primary care. However, primary care settings do not have effective models that can systematically integrate clinician-patient discussions and decision-making about ACP for older adults with and without cognitive impairment who still have decision making capacity. To address these gaps, we designed, refined with stakeholder input, and demonstrated the feasibility, acceptability, and efficacy of a theory-based and practical ACP group visit intervention, ENACT Group Visits (Engaging in Advance Care Planning Talks) among older primary care patients. ENACT Group Visits are two facilitated discussions, one month apart, led by a physician or advanced practice provider and a social worker. The intervention uses evidence-based ACP materials and leverages the group dynamic to promote patient goal-setting and self-efficacy. In a single-clinic pilot study, patients randomized to the ENACT Group Visits intervention had a 26% higher rate of ACP documents at 6 months, compared to a control arm of mailed ACP materials (p=0.007). This study aims to test the effectiveness of ENACT Group Visits to increase ACP documentation (one aspect of ACP) and to evaluate its effectiveness among patients across a spectrum of cognitive impairment, including early dementia. The proposed 2-arm, patient-level randomized trial will be conducted in five primary care clinics and is powered to compare ENACT Group Visits intervention vs control mailed ACP materials. We will use 1:1 allotment and patient-level block randomization by presence or absence of CI. The study will use components of PREPARE™, an evidence-based ACP program designed to decrease cognitive burden, and an easy-to-read advance directive. Aim 1 will determine the effectiveness of ENACT Group Visits vs control at 6 months to increase ACP documentation (primary outcome), ACP readiness, decision self-efficacy, and quality of communication (secondary outcomes). Aim 2 will determine whether the effectiveness of ENACT Group Visits intervention varies by cognitive impairment, including ADRD. Aim 3 will describe acceptability and feasibility, as well as intervention fidelity and implementation outcomes, of ENACT Group Visits intervention using qualitative and mixed methods. This primary care-based effectiveness trial of ENACT Group Visits intervention among older adults, including those with dementia, will generate needed evidence for implementing effective ACP interventions into real-world primary care settings.