Impact of an Advance Care Planning Video Intervention on Care of Short-Stay Nursing Home Patients

Post-Acute Care Rehabilitation for Persons Living With Dementia: A Systematic Review

OBJECTIVES

To identify the results of post-acute care (PAC) rehabilitation for persons living with dementia (PLWD).

DESIGN

Systematic review of published literature without date restrictions through April 2023.

SETTING AND PARTICIPANTS

PLWD undergoing rehabilitation in PAC facilities after an acute care hospitalization.

METHODS

A systematic search was carried out in PubMed, Scopus, Google Scholar, Embase, Medline, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Included studies were peer-reviewed, available in English, and focused on PLWD admitted to rehabilitation facilities following hospitalization in the US and international settings. Studies on long-term care and acute inpatient rehabilitation units were excluded. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. A narrative synthesis approach was used for analysis of results with rehabilitation themes encompassing "outcomes" and "experiences."

RESULTS

Forty-one articles met inclusion criteria, with a heterogeneity of study designs including observational (n = 33), randomized clinical trials (n = 3), and qualitative studies (n = 5). Narrative synthesis demonstrated that PAC rehabilitation for PLWD contained themes of "outcomes," including health service utilization and physical and cognitive function, providing evidence for a lower likelihood to return home and achieving less functional improvement compared to individuals without cognitive impairment. The second theme, "experiences," included health care transitions, knowledge and education, goal alignment, and care models. Findings detailed poor communication around care transitions, lack of dementia knowledge among health care workers, goal alignment strategies, and innovative rehabilitation models specific for PLWD.

CONCLUSIONS AND IMPLICATIONS

Overall, this systematic review covers a breadth of literature across time and international settings on PAC rehabilitation for PLWD. The findings highlight the importance of rehabilitation models specific for dementia care, with a need for personalized approaches around care transitions, goal setting, and increased dementia education. Addressing these aspects of rehabilitative care for PLWD may enhance the delivery of PAC and improve health care outcomes and experiences.

Effectiveness of initiating advance care planning among older outpatients through intervention by physicians trained in a model discussion video: A randomized controlled trial

AIM

This study aimed to assess the impact of a physician-led intervention on advance care planning (ACP) introduction among older outpatients using a model discussion video.

METHODS

This prospective interventional study included Japanese general practice outpatients aged ≥65 years. All participants received an ACP leaflet. Co-researchers were trained using a model discussion video based on the "Serious Illness Conversation Guide," and provided ACP introduction explanations to the intervention group to ensure intervention content consistency. The control group received the ACP leaflet only, with no standardized explanations. The primary outcome was ACP discussion occurrence. Secondary outcomes included ACP engagement (assessed through the 4-item ACP Engagement Survey), engagement score for advance directives acquisition and score for surrogate decision-maker identification, and anxiety incidence (assessed through Generalized Anxiety Disorder-7).

RESULTS

This study included 48 participants: 25 (52.1%) in the intervention group and 23 (47.9%) in the control group. Regarding primary outcome, the intervention group had significantly more ACP discussions compared with the control group (92.0% vs 26.1%, adjusted odds ratio 50.2, P = 0.0012). Regarding secondary outcomes, the intervention group showed greater readiness (mean scores for the 4-item Engagement Survey [P = 0.0001], engagement score for advance directives acquisition [P = 0.01] and score for surrogate decision-maker determination [P = 0.03]) than the control group, without increasing anxiety.

CONCLUSIONS

This physician-led ACP introduction for older patients in a Japanese general practice setting enhanced ACP readiness and stimulated discussions, without increasing anxiety. The model discussion video for ACP introduction might effectively train physicians in general practice settings. Geriatr Gerontol Int 2024; ••: ••-••.

Tools for tomorrow: a scoping review of patient-facing tools for advance care planning

Advance care planning (ACP) supports individuals in aligning their medical care with personal values and preferences in the face of serious illness. The variety of ACP tools available reflects diverse strategies intended to facilitate these critical conversations, yet evaluations of their effectiveness often show mixed results. Following the Arskey and O'Malley framework, this scoping review aims to synthesize the range of ACP tools targeted at patients and families, highlighting their characteristics and delivery methods to better understand their impact and development over time. Studies included focused on patient-facing ACP tools across all settings and mediums. Exclusions were applied to studies solely targeting healthcare providers or those only aiming at completion of advance directives without broader ACP discussions. Searches were conducted across PubMed, Embase, CINAHL, The Cochrane Library, and Web of Science. Data were extracted using a predesigned spreadsheet, capturing study population, setting, intervention modality, and intervention theme. Tools were categorized by delivery method and further analyzed through a year-wise distribution to track trends and developments. We identified 99 unique patient-facing tools, with those focusing on counseling (31) and video technologies (21) being the most prevalent while others incorporated online platforms, print materials, games, or some combination of different delivery methods. Over half the tools were designed for specific patient groups, especially for various diseases and racial or ethnic communities. Recent years showed a surge in tool variety and innovation, including integrated patient portals and psychological techniques. The review demonstrates a broad array of innovative ACP tools that facilitate personalized and effective ACP. Our findings contribute to an enhanced understanding of their utilization and potential impacts, offering valuable insights for future tool development and policy making in ACP.

Spending Analysis of Machine Learning-Based Communication Nudges in Oncology

BACKGROUND

Serious illness conversations (SICs) in the outpatient setting may improve mood and quality of life among patients with cancer and decrease aggressive end-of-life care. Interventions informed by behavioral economics may increase rates of SICs between oncology clinicians and patients, but the impact of these interventions on end-of-life spending is unknown.

METHODS

This study is a secondary analysis of a stepped-wedge cluster randomized, controlled trial that involved nine medical oncology practices and their high-risk patients at a large academic institution between June 2019 and April 2020. The study included 1187 patients who were identified by a machine-learning algorithm as high risk of 180-day mortality and who died by December 2020. The patients were randomly assigned to standard of care (controls) or to a behavioral intervention designed to increase clinician-initiated SICs. We abstracted spending - defined as inflation-adjusted costs for acute care (inpatient plus emergency room), office/outpatient care, intravenous systemic therapy, other therapy (e.g., radiation), long-term care, and hospice - from the institution's accounting system, and we captured spending at inpatient, outpatient, and pharmacy settings. To evaluate intervention impacts on spending, we used a two-part model, first using logistic regression to model zero versus nonzero spending and second using generalized linear mixed models with gamma distribution and log-link function to model daily mean spending in the last 180days of life. Models were adjusted for clinic and wedge fixed effects, and they were clustered at the oncologist level. For all patients with at least one SIC within 6 months of death, we also calculated their mean daily spending before and after SIC.

RESULTS

Median age at death was 68years (interquartile range, 15.5), 317 patients (27%) were Black or of ethnicities other than white, and 448 patients (38%) had an SIC. The intervention was associated with lower unadjusted mean daily spending in the last 6 months of life for the intervention group versus controls ($377.96 vs. $449.92; adjusted mean difference, -$75.33; 95% confidence interval, -$136.42 to -$14.23; P=0.02), translating to $13,747 total adjusted savings per decedent and $13 million in cumulative savings across all decedents in the intervention group. Compared with controls, patients in the intervention group incurred lower mean daily spending for systemic therapy (adjusted difference, -$44.59; P=0.001), office/outpatient care (-$9.62; P=0.001), and other therapy (-$8.65; P=0.04). The intervention was not associated with differences in end-of-life spending for acute care, long-term care, or hospice. Results were consistent for spending in the last 1 and 3 months of life and after adjusting for age, race, and ethnicity. For patients with SICs, mean daily spending decreased by $37.92 following the first SIC ($329.87 vs. $291.95).

CONCLUSIONS

A machine learning-based, behaviorally informed intervention to prompt SICs led to end-of-life savings among patients with cancer, driven by decreased systemic therapy and outpatient spending. (Funded by the Penn Center for Precision Medicine and the National Institutes of Health; ClinicalTrials.gov number, NCT03984773.).

Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

Alzheimer's disease and related dementia (ADRD) is a major cause of death in the United States. While effective interventions have been developed to deliver palliative care to nursing home residents with ADRD, little work has identified effective interventions to reach assisted living (AL) residents with dementia.

RESEARCH DESIGN AND METHODS

One hundred and eighteen AL residents with dementia from 10 different ALs in Florida participated. A pilot study using a cluster randomized trial was conducted, with 6 sites randomized to receive a palliative care educational intervention for staff (N = 23) to deliver care to residents; 4 sites were usual care. The feasibility of the intervention was assessed by examining recruitment, retention, and treatment fidelity at 6 months. Cohen's d statistic was used to calculate facility-level treatment effect sizes on key outcomes (documentation of advance care planning [ACP] discussions, hospice admission, and documentation of pain screening).

RESULTS

The intervention proved feasible with high ratings of treatment fidelity. The intervention also demonstrated preliminary evidence for efficacy of the intervention, with effect sizes for the treatment group over 0.80 for increases in documentation of ACP discussions compared to the control group. Hospice admissions had a smaller effect size (0.16) and documentation of pain screenings had no effect.

DISCUSSION AND IMPLICATIONS

The pilot results suggest that the intervention shows promise as a resource for educating and empowering AL staff on implementing person-centered palliative care delivery to persons with dementia in AL. A larger, fully powered randomized trial is needed to test for its efficacy.

Effect of application of short-form video health education on the health knowledge and satisfaction with nursing care of patients with lower extremity fractures

BACKGROUND

Video health education has been increasingly adopted in the clinic to expand patient guidance and improve perioperative outcomes. To date, however, it is unclear whether the use of short-form videos and web-based clinician-created forums actually improve the perioperative experience of patients.

OBJECTIVE

To evaluate the effect of application of short-form video health education on the health knowledge and satisfaction with nursing care of patients with lower extremity fractures.

METHODS

This study is a quasi experimental study, using convenient sampling method and grouping according to historical control., one hundred and twenty-two patients admitted with lower limb fractures to the orthopedic ward of a tertiary first-class general hospital in Fujian, China were enrolled in this study. Based on their admission order, patients admitted from September 2021 to November 2021 were enrolled into the control group (n = 61) and patients admitted from December 2021 to March 2022 were enrolled in the intervention group (n = 61). Both groups received identical admission-based patient education, perioperative care, and discharge rehabilitation instructions. The control group received the traditional education method while the intervention group received a short-form educational video in addition to the traditional education method. Patient perioperative health knowledge and patient satisfaction with nursing care during treatment of lower limb fractures were compared across the two groups.

RESULTS

Preoperative health knowledge in the intervention group was 95.1%, compared to 82.0% in the control group (χ2 = 3.954, P<0.05). The Newcastle satisfaction with nursing scales score in the intervention group was (80.902 ± 7.016) points, compared to (78.131 ± 8.213) points in the control group. These group differences were statistically significant (P < 0.05).

CONCLUSION

The application of a short-form educational video during the perioperative care of patients with lower limb fractures may improve patients' understanding of perioperative health and increase satisfaction with nursing care.

The Effectiveness of Video Decision Aid on Advance Care Planning With Adult Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The purpose of this review was to examine the effect of video decision aids on adult patients' advance care planning-related outcomes. Seven English electronic databases (PubMed, Cochrane, MEDLINE, EMBASE, PsycINFO, CINAHL, OpenGray) and 3 Chinese databases (CNKI, WanFang, and VIP) were searched to identify relevant studies. Fourteen randomized controlled trials were included. The results of the meta-analysis showed that video decision aids reduced patients' preferences for life-prolonging care (risk ratio [RR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .01), cardiopulmonary resuscitation (RR, 0.54; 95% CI, 0.46-0.64; P < .01), and intubation tube placement (RR, 1.65; 95% CI, 1.09-2.48; P = .02) and increased patients' willingness to have a goals-of-care conversation (RR, 1.87; 95% CI, 1.32-2.65; P = .0004) and knowledge of advance care planning (RR, 0.80; 95% CI, 0.50-1.09; P < .01). However, because of the variability among the studies, the results have limitations. Future research needs to increase the sample size and improve the experimental design to confirm the impact of video decision aids on advance care planning.

The Effect of Advance Care Planning Intervention on Hospitalization Among Nursing Home Residents: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effect of advance care planning (ACP) interventions on the hospitalization of nursing home residents.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Nursing homes and nursing home residents.

METHODS

A literature search was systematically conducted in 6 electronic databases (Embase, Ovid MEDLINE, Cochrane Library, CINAHL, AgeLine, and the Psychology & Behavioral Sciences Collection), in addition to hand searches and reference list checking; the articles retrieved were those published from 1990 to November 2021. The eligible studies were randomized controlled trials, controlled trials, and pre-post intervention studies describing original data on the effect of ACP on hospitalization of nursing home residents; these studies had to be written in English. Two independent reviewers appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022301648).

RESULTS

The initial search yielded 744 studies. Nine studies involving a total of 57,180 residents were included in the review. The findings showed that the ACP reduced the likelihood of hospitalization [relative risk (RR) 0.54, 95% CI 0.47-0.63; I² = 0%)], it had no effect on emergency department (ED) visits (RR 0.60, 95% CI 0.31-1.42; I² = 99), hospice enrollment (RR 0.98, 95% CI 0.88-1.10; I² = 0%), mortality (RR 0.83, 95% CI 0.68-1.00; I² = 4%), and satisfaction with care (standardized mean difference: -0.04, 95% CI -0.14 to -0.06; I² = 0%).

CONCLUSION AND IMPLICATIONS

ACP reduced hospitalizations but did not affect the secondary outcomes, namely, ED visits, hospice enrollment, mortality, and satisfaction with care. These findings suggest that policy makers should support the implementation of ACP programs in nursing homes. More robust studies are needed to determine the effects of ACP on ED visits, hospice enrollment, mortality, and satisfaction with care.

Evaluating implementation strategies to support documentation of veterans' care preferences

OBJECTIVE

To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented.

DATA SOURCES

Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020.

STUDY DESIGN

In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites.

DATA COLLECTION METHODS

Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation.

PRINCIPAL FINDINGS

LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72).

CONCLUSIONS

Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support.

What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials

Objectives

To conduct an up-to-date systematic review of all randomised controlled trials assessing efficacy of advance care planning (ACP) in improving patient outcomes, healthcare use/costs and documentation.

Design

Narrative synthesis conducted for randomised controlled trials. We searched electronic databases (MEDLINE/PubMed, Embase and Cochrane databases) for English-language randomised or cluster randomised controlled trials on 11 May 2020 and updated it on 12 May 2021 using the same search strategy. Two reviewers independently extracted data and assessed methodological quality. Disagreements were resolved by consensus or a third reviewer.

Results

We reviewed 132 eligible trials published between 1992 and May 2021; 64% were high-quality. We categorised study outcomes as patient (distal and proximal), healthcare use and process outcomes. There was mixed evidence that ACP interventions improved distal patient outcomes including end-of-life care consistent with preferences (25%; 3/12 with improvement), quality of life (0/14 studies), mental health (21%; 4/19) and home deaths (25%; 1/4), or that it reduced healthcare use/costs (18%; 4/22 studies). However, we found more consistent evidence that ACP interventions improve proximal patient outcomes including quality of patient–physician communication (68%; 13/19), preference for comfort care (70%; 16/23), decisional conflict (64%; 9/14) and patient-caregiver congruence in preference (82%; 18/22) and that it improved ACP documentation (a process outcome; 63%; 34/54).

Conclusion

This review provides the most comprehensive evidence to date regarding the efficacy of ACP on key patient outcomes and healthcare use/costs. Findings suggest a need to rethink the main purpose and outcomes of ACP.

PROSPERO registration number

CRD42020184080.

Effect of advance care planning video on do-not-hospitalize orders for nursing home residents with advanced illness

BACKGROUND

The purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness.

METHODS

Secondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the ACP Video Program: 69 NHs in control arm employed usual ACP practices). Participants included long (> 100 days) and short (≤ 100 days) stay residents with advanced illness (advanced dementia or cardiopulmonary disease (chronic obstructive pulmonary disease or congestive heart failure)) in NHs from March 1, 2016 to May 31, 2018 without a documented Do-Not-Hospitalize (DNH) order at baseline. Logistic regression with covariate adjustments was used to estimate the impact of the resident being in a treatment versus control NH on: the proportion of residents with new DNH orders during follow-up; and the proportion of residents with any hospitalization during follow-up. Clustering at the facility-level was addressed using hierarchical models.

RESULTS

The cohort included 6,117 residents with advanced illness (mean age (SD) = 82.8 (8.4) years, 65% female). Among long-stay residents (n = 3,902), 9.3% (SE, 2.2; 95% CI 5.0-13.6) and 4.2% (SE, 1.1; 95% CI 2.1-6.3) acquired a new DNH order in the treatment and control arms, respectively (average marginal effect, (AME) 5.0; SE, 2.4; 95% CI, 0.3-9.8). Among short-stay residents with advanced illness (n = 2,215), 8.0% (SE, 1.6; 95% CI 4.6-11.3) and 3.5% (SE 1.0; 95% CI 1.5-5.5) acquired a new DNH order in the treatment and control arms, respectively (AME 4.4; SE, 2.0; 95% CI, 0.5-8.3). Proportion of residents with any hospitalizations did not differ between arms in either cohort.

CONCLUSIONS

Compared to usual care, an ACP Video Program intervention increased documented DNH orders among NH residents with advanced disease but did not significantly reduce hospitalizations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02612688 .

Pragmatic Trials in Long-Term Care: Implementation and Dissemination Challenges and Opportunities

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce findings that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants identified 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) stakeholder engagement, (2) diversity and inclusion, (3) organizational strain and readiness, and (4) learn from adaptations. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.

Effect of a Video-Assisted Advance Care Planning Intervention on End-of-Life Health Care Transitions Among Long-Stay Nursing Home Residents

OBJECTIVE

To determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness.

DESIGN

Pragmatic cluster randomized clinical trial. Five ACP videos were available on tablets or online at intervention facilities. PROVEN champions employed by nursing homes (usually social workers) were directed to offer residents (or their proxies) ≥1 video under certain circumstances. Control facilities employed usual ACP practices.

SETTING AND PARTICIPANTS

PROVEN occurred from February 2016 to May 2019 in 360 nursing homes (119 intervention, 241 control) owned by 2 health care systems. This post hoc study of PROVEN data analyzed long-stay residents ≥65 years who died during the trial who had either advanced dementia or cardiopulmonary disease (advanced illness). We required an observation time ≥90 days before death. The analytic sample included 923 and 1925 advanced illness decedents in intervention and control arms; respectively.

METHODS

Outcomes included the proportion of residents with 1 or more hospital transfer (ie, hospitalization, emergency department use, or observation stay), multiple (≥3) hospital transfers during the last 90 days of life, and late transitions (ie, hospital transfer during the last 3 days or hospice admission on the last day of life).

RESULTS

Hospital transfers in the last 90 days of life among decedents with advanced illness were significantly lower in the intervention vs control arm (proportion difference = -1.7%, 95% CI -3.2%, -0.1%). The proportion of decedents with multiple hospital transfers and late transitions did not differ between the trial arms.

CONCLUSIONS AND IMPLICATIONS

Video-assisted ACP was modestly associated with reduced hospital transfers in the last 90 days of life among nursing home residents with advanced illness. The intervention was not significantly associated with late health care transitions and multiple hospital transfers.

A Pragmatic Clinical Trial Approach to Assessing and Monitoring Suicidal Ideation: Results from A National US Trauma Care System Study

OBJECTIVE

Few investigations have comprehensively described methods for assessing and monitoring suicidal ideation in pragmatic clinical trials of mental health services interventions. This investigation's goal was to assess a collaborative care intervention's effectiveness in reducing suicidal ideation and describe suicide monitoring implementation in a nationwide protocol.

METHOD

The investigation was a secondary analysis of a stepped wedge cluster randomized trial at 25-Level I trauma centers. Injury survivors (N = 635) were randomized to control (n = 370) and intervention (n = 265) conditions and assessed at baseline hospitalization and follow-up at 3-, 6- and 12-months post-injury. The Patient Health Questionnaire (PHQ-9) item-9 was used to evaluate patients for suicidal ideation. Mixed model regression was used to assess intervention versus control group changes in PHQ-9 item-9 scores over time and associations between baseline characteristics and development of suicidal ideation longitudinally. As part of the study implementation process assessment, suicide outreach call logs were also reviewed.

RESULTS

Over 50% of patients endorsed suicidal ideation at ≥1 assessment. Intervention patients relative to control patients demonstrated reductions in endorsements of suicidal ideation that did not achieve statistical significance (F[3,1461] = 0.74, P = .53). The study team completed outreach phone calls, texts or voice messages to 268 patients with PHQ-9 item-9 scores ≥1 (n = 161 control, n = 107 intervention).

CONCLUSIONS

Suicide assessment and monitoring can be feasibly implemented in large-scale pragmatic clinical trials. Intervention patients demonstrated less suicidal ideation over time; however, these comparisons did not achieve statistical significance. Intensive pragmatic trial monitoring may mask treatment effects by providing control patients a supportive intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02655354.

Pragmatic Trials in Long-Term Care: Challenges, Opportunities, Recommendations

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce data that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants recommended 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) engage stakeholders, (2) ensure diversity and inclusion, (3) assess organizational strain and readiness, and (4) learn from adaptations. Specifically related to implementation, participants provided 2 recommendations: (1) integrate interventions into existing workflows and (2) maintain agility and responsiveness. Finally, participants had 3 recommendations specific to dissemination: (1) package the message for the audience, (2) engage diverse audiences, and (3) apply dissemination and diffusion tools. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.

Postacute care outcomes in home health or skilled nursing facilities in patients with a diagnosis of dementia

OBJECTIVE

To compare the outcomes of postacute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with a diagnosis of dementia.

DATA SOURCES

100% MedPAR data, Minimum Data Set, and Outcome and Assessment Information Set assessment data from January 1, 2015 to December 31, 2016.

STUDY DESIGN

Retrospective cohort analysis using an instrumental variable design to compare outcomes (30-day readmission and mortality, 100-day mortality) of HH versus SNF following acute hospitalization. We used the differential distance between patients' home and the closest HH agency and SNF to instrument for nonrandom allocation of patients.

DATA COLLECTION/EXTRACTION METHODS

We identified hospital discharges followed by SNF and HH stays for Medicare fee-for-service beneficiaries with dementia. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or enrolled in hospice. We identified dementia using validated diagnostic codes with a 3-year look-back.

PRINCIPAL FINDINGS

Our sample included 977,946 beneficiaries with a diagnosis of dementia; 297,732 (30.4%) received HH, while 680,214 (69.6%) went to SNF. Overall, 16.8% were readmitted to the hospital and 6.1% died within 30 days, while 15.4% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two postacute care settings.

CONCLUSIONS

Medicare beneficiaries with a diagnosis of dementia receiving postacute care in HH or SNF experienced similar rates of readmission and mortality across settings. This finding raises important questions about current postacute care referral patterns, given 7 in 10 patients with a diagnosis of dementia in our sample were discharged to SNF.