Using the Electronic Health Record to Identify and Promote Goals-of-Care Communication for Older Patients with Serious Illness

使用电子健康记录来识别和促进老年重病患者的护理目标沟通

• 批准号: 10616699
• 负责人: Ruth Ann Engelberg
• 金额: $ 77.74万
• 依托单位: UNIVERSITY OF WASHINGTON
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-06-15 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10616699
• 关键词: Accounting; Address; Admission activity; Adoption; Adult; Alzheimer' s disease patient; Alzheimer' s disease related dementia; Caring; Chronic Disease; Clinic Visits; Communication; Consensus; Cost Analysis; Dissemination and Implementation; Documentation; Effectiveness of Interventions; Elderly; Electronic Health Record; Evaluation; Family; Family member; Goals; Grant; Healthcare Systems; Hospitalization; Hospitals; Intensive Care; Intervention; Interview; Knowledge; Length of Stay; Link; Measures; Methods; Multicenter Trials; National Institute on Aging; Natural Language Processing; Outcome; Outcome Assessment; Outpatients; Palliative Care; Participant; Patient-Focused Outcomes; Patients; Quality of Care; Quality of life; Quantitative Evaluations; Randomized; Reach, Effectiveness, Adoption, Implementation, and Maintenance; Reporting; Sampling; Subgroup; Surveys; care costs; care outcomes; comparative effectiveness trial; cost; economic evaluation; effectiveness evaluation; effectiveness/implementation hybrid; efficacy evaluation; end of life; end of life care; experience; future implementation; hospital readmission; implementation framework; implementation science; improved; improved outcome; innovation; intervention cost; machine learning method; mortality; novel; older patient; palliative; patient subsets; pragmatic trial; preference; primary outcome; programs; psychological symptom; randomized trial; secondary outcome; symposium; treatment as usual

Although discussions that address patients' goals of care are one of the most important aspects of palliative care, this communication is often lacking in our healthcare system. Goals-of-care communication is associated with improved patient and family outcomes and reduced intensity of care at the end of life. Electronic health records (EHR) provide a key opportunity to identify patients who would benefit from these discussions and to promote these discussions, yet prior interventions have not used the EHR for this purpose. Older adults with chronic illness, and particularly those with Alzheimer's disease and related dementias (ADRD), are especially vulnerable to inappropriately intensive end-of-life care. To address this shortcoming, we build on two of our most successful programs, one using the EHR to identify goals-of-care discussions and the other a novel intervention called Jumpstart that promotes and enhances these discussions. We will examine the effectiveness of the Jumpstart intervention for hospitalized older adults with chronic illness and specifically oversample those with ADRD to understand the effectiveness of the intervention in this key group. We propose 2 linked, complementary randomized trials. Trial 1, a pragmatic trial, compares usual care with a clinician-facing Jumpstart for hospitalized older adults with serious illness (n=2000). Trial 2, a comparative effectiveness trial, compares this clinician-facing Jumpstart with a bi-directional, patient-specific Jumpstart based on surveys completed by patients or family members (n=400). We hypothesize that the clinician-facing Jumpstart will improve outcomes compared to usual care, and the bi-directional, patient- specific Jumpstart will improve outcomes compared to the clinician-facing Jumpstart. We use an innovative hybrid effectiveness-implementation approach to accomplish 3 aims. Aim 1 evaluates the effectiveness of the clinician-facing Jumpstart, compared with usual care, for improving quality of care; the primary outcome is EHR documentation of a goals-of-care discussion during the hospitalization. Secondary outcomes include intensity of care at the end of life. Aim 2 evaluates the effectiveness of the bi-directional, patient-specific Jumpstart compared to the clinician-facing Jumpstart; the primary outcome is the same as Trial 1. We will examine the same secondary outcomes, but also include patient- and family-reported outcomes assessed by surveys at 1 and 3 months after randomization including occurrence and quality of goals-of-care communication in the hospital, goal-concordant care, psychological symptoms, quality of life, and palliative care needs. We will also examine costs of care after accounting for costs of the interventions. In Aim 3, we conduct a mixed-methods evaluation to explore barriers and facilitators to future implementation and dissemination. Our team has experience conducting innovative multi-center trials with patient-centered outcomes, economic analyses, and implementation science. This novel hybrid effectiveness-implementation approach addresses key knowledge gaps to improve the quality and value of care for older adults.

尽管解决患者护理目标的讨论是最重要的方面之一 姑息治疗，我们的医疗保健系统往往缺乏这种沟通。护理沟通的目标是 与改善患者和家庭结局以及减少临终护理强度相关。 电子健康记录 (EHR) 提供了一个关键机会来识别哪些患者将从这些记录中受益 讨论并促进这些讨论，但之前的干预措施并未将 EHR 用于此目的。 患有慢性疾病的老年人，特别是患有阿尔茨海默病和相关痴呆症的老年人 （ADRD），特别容易受到不适当的强化临终关怀的影响。为了解决这个缺点， 我们以两个最成功的项目为基础，一个使用 EHR 来确定护理目标讨论， 另一个是名为 Jumpstart 的新颖干预措施，可以促进和加强这些讨论。我们将 检查 Jumpstart 干预措施对患有慢性病的住院老年人的有效性，以及 特别对 ADRD 患者进行过抽样，以了解干预措施对该关键群体的有效性。 我们提出了 2 项相互关联、互补的随机试验。试验 1，一项实用试验，比较了常规护理 为患有严重疾病的住院老年人 (n=2000) 提供面向临床医生的 Jumpstart。试验2，a 比较有效性试验，将这种面向临床医生的 Jumpstart 与双向、针对患者的 Jumpstart 基于患者或家庭成员完成的调查 (n=400)。我们假设 与常规护理相比，面向临床医生的 Jumpstart 将改善结果，并且双向、患者 与面向临床医生的 Jumpstart 相比，特定的 Jumpstart 将改善结果。我们使用创新的 混合有效性实施方法来实现 3 个目标。目标 1 评估的有效性 与常规护理相比，面向临床医生的 Jumpstart 可以提高护理质量；主要结果是 EHR 住院期间护理目标讨论的记录。次要结果包括强度 生命临终时的护理。目标 2 评估双向、针对患者的 Jumpstart 的有效性 与面向临床医生的 Jumpstart 相比；主要结果与试验 1 相同。我们将检查 相同的次要结果，但还包括通过 1 的调查评估的患者和家庭报告的结果 以及随机分组后 3 个月，包括护理目标沟通的发生率和质量 医院、目标一致护理、心理症状、生活质量和姑息治疗需求。我们还将 考虑干预措施的成本后检查护理成本。在目标 3 中，我们采用了混合方法 评估以探索未来实施和传播的障碍和促进因素。 我们的团队拥有进行以患者为中心的结果的创新多中心试验的经验， 经济分析和实施科学。这种新颖的混合有效性实施方法 解决关键知识差距，以提高老年人护理的质量和价值。