Group Visits for Advance Care Planning Among Older Adults with Heart Failure

背景：早期提前护理计划(ACP)对于患有心力衰竭(HF)的老年人至关重要，他们面临着不确定的 以日益复杂的治疗决定为标志的轨迹。心力衰竭在老年人中非常普遍，他们通常 有很高的共病负担，使疾病轨迹进一步复杂化，并对生命的使用产生影响- 延长干预时间。我们对机场核心计划的态度最近已从狭隘地关注预先指令转向帮助 患者在疾病轨迹的早期识别并传达他们广泛的医疗价值观，为他们在未来的 瞬间做出决定。不幸的是，患者-提供者讨论以下问题所需的时间、技能和资源 价值澄清通常会导致ACP通信延迟或被忽视。以团体访问的方式探讨价值观 澄清提供了规模经济，同时也利用社交学习的各个方面来增强患者对 ACP和价值澄清。虽然小组访问在慢性病管理中得到了有效的利用，但这 该模型尚未应用于非加太--价值澄清方面。 目的：确定以小组访问为重点的机场核心计划的可接受性、可行性和初步影响 在老年心力衰竭患者及其代理人中澄清价值，为计划中的R01试验做准备。 具体目标(1)根据老年心力衰竭患者、他们的代理人和 它们的主要提供者；以及(2)评估可接受性、可行性和对与机场核心计划相关的结果的初步影响 在老年心力衰竭患者、他们的代理人和他们的主要提供者中，ACP-HF小组的访问干预。 研究设计/方法：这是一项以价值观为重点的ACP-HF团体访问干预的混合方法研究 澄清。在目标1中，我们将进行3次原型ACP-HF小组访问和2次后续小组访问，然后进行 进行认知性访谈并进行简短调查，以获得参与者的有针对性的反馈。我们将使用调查来 征求患者参与者的主要提供者对原型小组访问总结笔记的反馈，以定制 团体访视干预与临床环境的沟通。我们将使用这些数据来改进行为 并对原型课程进行干预，为中试做准备。在目标2中，我们将试行6个ACP-HF小组 走访和2次后续小组访问，并评估与机场核心计划相关的可接受性、可行性和初步影响 通过调查前评估、半结构化访谈、有组织地观察 小组访问和探索性统计分析。我们还将收集主要提供商对感知到的 向他们提供的有关他们的患者参与小组访问的信息的实用性和质量。 影响：这项研究的结果将为计划中的R01试验提供方法学和后勤基础 目的：评价ACP-HF团体访视干预的效果。这项研究也将促进我们对 如何有效地将复杂而耗时的价值澄清过程融入临床实践 通过使用团体访问的方式。

Background: Early advance care planning (ACP) is critical for older adults with heart failure (HF), who face an uncertain trajectory marked by increasingly complex treatment decisions. HF is highly prevalent among the elderly, who typically have a high burden of comorbidity that further complicates the disease trajectory, with implications for the use of life- prolonging interventions. Our approach to ACP has recently shifted from a narrow focus on advance directives to helping patients identify and communicate their broad healthcare values early in the illness trajectory to prepare them for in-the- moment decision making. Unfortunately, the time, skills, and resources required for patient-provider discussions about values clarification often results in delayed or overlooked ACP communication. A group visit approach to values clarification offers economies of scale while also leveraging aspects of social learning to enhance patient engagement in ACP and values clarification. Although group visits have been effectively used in chronic disease management, this model has not yet been applied to the ACP-values clarification context. Purpose: To establish the acceptability, feasibility and preliminary impact of using group visits for ACP focused on values clarification among elderly HF patients and their surrogates in preparation for a planned R01 trial. Specific Aims (1) Refine an ACP-HF group visit intervention based on input from older HF patients, their surrogates, and their primary providers; and (2) Evaluate the acceptability, feasibility and preliminary impact on ACP-relevant outcomes of the ACP-HF group visit intervention among older HF patients, their surrogates, and their primary providers. Research Design/Methods: This is a mixed-methods study of an ACP-HF group visit intervention focused on values clarification. In Aim 1, we will conduct 3 prototype ACP-HF group visits and 2 follow-up group visits and then conduct cognitive interviews and administer brief surveys to elicit focused feedback from participants. We will use surveys to elicit feedback from the patient participants' primary providers on a prototype group visit summary note to tailor the communication between the group visit intervention and the clinical setting. We will use these data to refine the conduct and curriculum of the prototype intervention in preparation for pilot-testing. In Aim 2, we will pilot 6 ACP-HF group visits and 2 follow-up group visits and assess the acceptability, feasibility, and preliminary impact on ACP-relevant outcomes of the visits through pre-post survey evaluations, semi-structured interviews, structured observations of the group visits, and exploratory statistical analyses. We will also collect feedback from primary providers on the perceived utility and quality of the information provided to them about their patients' participation in the group visits. Implications: Findings from this study will provide the methodological and logistical foundation for a planned R01 trial to evaluate the effectiveness of an ACP-HF group visit intervention. This study will also advance our understanding of how to efficiently incorporate the complex and time-consuming process of values clarification into clinical practice through the use of group visits.