Dataset Information

Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial.

ABSTRACT:

Importance

Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians.

Objective

To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation.

Design, setting, and participants

This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022.

Intervention

The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care.

Main outcome and measures

The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing.

Results

A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase.

Conclusions and relevance

In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool.

Trial registration

ClinicalTrials.gov Identifier: NCT04857060.

SUBMITTER: Volandes AE

PROVIDER: S-EPMC10495866 | biostudies-literature | 2023 Sep

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial.

Volandes Angelo E AE Zupanc Sophia N SN Lakin Joshua R JR Cabral Howard J HJ Burns Edith A EA Carney Maria T MT Lopez Santiago S Itty Jennifer J Emmert Kaitlin K Martin Narda J NJ Cole Therese T Dobie Alexandra A Cucinotta Traci T Joel Milton M Caruso Lisa B LB Henault Lori L Dugas Julianne N JN Astone Kristina K Winter Michael M Wang Na N Davis Aretha Delight AD Garde Cynthia C Rodriguez Perla Macip PM El-Jawahri Areej A Moseley Edward T ET Das Sophiya S Sciacca Kate K Ramirez Ana Maria AM Gromova Valeria V Lambert Sherene S Sanghani Shreya S Lindvall Charlotta C Paasche-Orlow Michael K MK

JAMA network open 20230905 9

<h4>Importance</h4>Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians.<h4>Objective</h4>To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation.<h4>Design, setting, and participants</h4>This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban ho ...[more]

PMID: 37695586

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Project description:ImportanceCOVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models.ObjectiveTo assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients.Design, setting, and participantsThe Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included.Main outcomes and measuresThe primary outcome was ACP documentation.ResultsA total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001).Conclusions and relevanceThis intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients.Trial registrationClinicalTrials.gov Identifier: NCT04660422.

Project description:To evaluate whether race influences agreement between screening results and documentation of cognitive impairment and delirium.Secondary data analysis.An urban, public hospital and healthcare system.Hospitalized older adults aged 65 and older admitted to general inpatient medical services evaluated for cognitive impairment (n = 851) and evaluated for delirium (n = 424).Cognitive impairment and delirium were measured in each participant using the Short Portable Mental Status Questionnaire (SPMSQ) and the Confusion Assessment Method (CAM), respectively, as the reference identification method. Clinical documentation of cognitive impairment and delirium was defined according to the presence of International Classification of Diseases, Ninth Revision (ICD-9), codes from within 1 year before hospitalization through discharge for cognitive impairment or from hospital admission through discharge for delirium.Two hundred ninety-four participants (34%) had cognitive impairment based on SPMSQ performance, and 163 (38%) had delirium based on CAM results. One hundred seventy-one (20%) of those with cognitive impairment had an ICD-9 code for cognitive impairment, whereas 92 (22%) of those with delirium had an ICD-9 code for delirium. After considering age, sex, education, socioeconomic status, chronic comorbidity, and severity of acute illness, of those who screened positive on the SPMSQ, African Americans had a higher adjusted odds ratio (AOR) than non-African Americans for clinical documentation of cognitive impairment (AOR = 1.66, 95% confidence interval (CI) = 0.95-2.89), and of those who screened negative on the SPMSQ, African Americans had higher odds of clinical documentation of cognitive impairment (AOR = 2.10, 95% CI = 1.17-3.78) than non-African Americans. There were no differences in clinical documentation rates of delirium between African Americans and non-African Americans.Racial differences in coding for cognitive impairment may exist, resulting in higher documentation of cognitive impairment in African Americans screening positive or negative for cognitive impairment.

Project description:Rationale & objectiveElicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study.Study designRetrospective cohort study.Setting & participantsA random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and 2010.ExposuresDemographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences.OutcomesDocumented discussions of dialysis treatment and supportive care.Analytical approachWe reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions.ResultsThe cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics.LimitationsDocumentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited.ConclusionsAmong older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.

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Project description:BackgroundGuidelines recommend Advance Care Planning (ACP) for seriously ill older adults to increase the patient-centeredness of end-of-life care. Few interventions target the inpatient setting.ObjectiveTo test the effect of a novel physician-directed intervention on ACP conversations in the inpatient setting.DesignStepped wedge cluster-randomized design with five 1-month steps (October 2020-February 2021), and 3-month extensions at each end.SettingA total of 35/125 hospitals staffed by a nationwide physician practice with an existing quality improvement initiative to increase ACP (enhanced usual care).ParticipantsPhysicians employed for ≥ 6 months at these hospitals; patients aged ≥ 65 years they treated between July 2020-May 2021.InterventionGreater than or equal to 2 h of exposure to a theory-based video game designed to increase autonomous motivation for ACP; enhanced usual care.Main measureACP billing (data abstractors blinded to intervention status).ResultsA total of 163/319 (52%) invited, eligible hospitalists consented to participate, 161 (98%) responded, and 132 (81%) completed all tasks. Physicians' mean age was 40 (SD 7); most were male (76%), Asian (52%), and reported playing the game for ≥ 2 h (81%). These physicians treated 44,235 eligible patients over the entire study period. Most patients (57%) were ≥ 75; 15% had COVID. ACP billing decreased between the pre- and post-intervention periods (26% v. 21%). After adjustment, the homogeneous effect of the game on ACP billing was non-significant (OR 0.96; 95% CI 0.88-1.06; p = 0.42). There was effect modification by step (p < 0.001), with the game associated with increased billing in steps 1-3 (OR 1.03 [step 1]; OR 1.15 [step 2]; OR 1.13 [step 3]) and decreased billing in steps 4-5 (OR 0.66 [step 4]; OR 0.95 [step 5]).ConclusionsWhen added to enhanced usual care, a novel video game intervention had no clear effect on ACP billing, but variation across steps of the trial raised concerns about confounding from secular trends (i.e., COVID).Trial registrationClinicaltrials.gov; NCT04557930, 9/21/2020.

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Project description:ImportanceHealth care systems need effective models to manage chronic diseases like tobacco dependence across transitions in care. Hospitalizations provide opportunities for smokers to quit, but research suggests that hospital-delivered interventions are effective only if treatment continues after discharge.ObjectiveTo determine whether an intervention to sustain tobacco treatment after hospital discharge increases smoking cessation rates compared with standard care.Design, setting, and participantsA randomized clinical trial compared sustained care (a postdischarge tobacco cessation intervention) with standard care among 397 hospitalized daily smokers (mean age, 53 years; 48% were males; 81% were non-Hispanic whites) who wanted to quit smoking after discharge and received a tobacco dependence intervention in the hospital; 92% of eligible patients and 44% of screened patients enrolled. The study was conducted from August 2010 through November 2012 at Massachusetts General Hospital.InterventionsSustained care participants received automated interactive voice response telephone calls and their choice of free smoking cessation medication (any type approved by the US Food and Drug Administration) for up to 90 days. The automated telephone calls promoted cessation, provided medication management, and triaged smokers for additional counseling. Standard care participants received recommendations for postdischarge pharmacotherapy and counseling.Main outcomes and measuresThe primary outcome was biochemically confirmed past 7-day tobacco abstinence at 6-month follow-up after discharge from the hospital; secondary outcomes included self-reported tobacco abstinence.ResultsSmokers randomly assigned to sustained care (n = 198) used more counseling and more pharmacotherapy at each follow-up assessment than those assigned to standard care (n = 199). Biochemically validated 7-day tobacco abstinence at 6 months was higher with sustained care (26%) than with standard care (15%) (relative risk [RR], 1.71 [95% CI, 1.14-2.56], P = .009; number needed to treat, 9.4 [95% CI, 5.4-35.5]). Using multiple imputation for missing outcomes, the RR for 7-day tobacco abstinence was 1.55 (95% CI, 1.03-2.21; P = .04). Sustained care also resulted in higher self-reported continuous abstinence rates for 6 months after discharge (27% vs 16% for standard care; RR, 1.70 [95% CI, 1.15-2.51]; P = .007).Conclusions and relevanceAmong hospitalized adult smokers who wanted to quit smoking, a postdischarge intervention providing automated telephone calls and free medication resulted in higher rates of smoking cessation at 6 months compared with a standard recommendation to use counseling and medication after discharge. These findings, if replicated, suggest an approach to help achieve sustained smoking cessation after a hospital stay.Trial registrationclinicaltrials.gov Identifier: NCT01177176.

Dataset Information

Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial.

Importance

Objective

Design, setting, and participants

Intervention

Main outcome and measures

Results

Conclusions and relevance

Trial registration

Publications

Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial.

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