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Shi S, Largent EA, McCreedy E, Mitchell SL. Design Considerations for Embedded Pragmatic Clinical Trials of Advance Care Planning Interventions for Persons Living With Dementia. J Pain Symptom Manage 2023; 65:e155-e163. [PMID: 36423803 PMCID: PMC9875559 DOI: 10.1016/j.jpainsymman.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/23/2022]
Abstract
Advance care planning (ACP) is an important part of comprehensive care for persons living with dementia (PLWD). While many trials have established the efficacy of ACP in improving end-of-life communication and documentation of care preferences, there remains a gap in clinical usage. Embedded pragmatic clinical trials (ePCTs) may facilitate the uptake of evidence-based care into existing healthcare by deploying efficacious ACP interventions into real-world settings. However rigorous conduct of ePCTs of ACP for PLWD presents several unique methodological considerations. Here we describe a framework for the construction of these research studies, with a focus on distinguishing between the target of study: the PLWD, their care partners, or both. We outline specific considerations at each step of the research study process including 1) participant identification/eligibility, 2) participant recruitment/enrollment, 3) intervention implementation, and 4) outcome selection/ascertainment. These considerations are weighed in further detail by describing the approaches from three published trials. Specifically, we consider how potential challenges were overcome by tradeoffs in study design. Finally, we offer directions for future growth to advance ePCTs for ACP among PLWD and catalyze future research.
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Affiliation(s)
- Sandra Shi
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research (S.S., S.L.M.), Boston, MA, USA.
| | - Emily A Largent
- University of Pennsylvania Perelman School of Medicine (E.A.L.), Philadelphia, PA, USA
| | - Ellen McCreedy
- Brown University School of Public Health (E.M.), Providence, RI, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research (S.S., S.L.M.), Boston, MA, USA
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Vitamin D3 Supplementation at 5000 IU Daily for the Prevention of Influenza-like Illness in Healthcare Workers: A Pragmatic Randomized Clinical Trial. Nutrients 2022; 15:nu15010180. [PMID: 36615837 PMCID: PMC9823308 DOI: 10.3390/nu15010180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 01/04/2023] Open
Abstract
Vitamin D supplementation has been shown to reduce the incidence of acute respiratory infections in populations at risk. The COVID-19 pandemic has highlighted the importance of preventing viral infections in healthcare workers. The aim of this study was to assess the hypothesis that vitamin D3 supplementation at 5000 IU daily reduces influenza-like illness (ILI), including COVID-19, in healthcare workers. We conducted a prospective, controlled trial at a tertiary university hospital. A random group of healthcare workers was invited to receive 5000 IU daily vitamin D3 supplementation for nine months, while other random healthcare system workers served as controls. All healthcare workers were required to self-monitor and report to employee health for COVID-19 testing when experiencing symptoms of ILI. COVID-19 test results were retrieved. Incidence rates were compared between the vitamin D and control groups. Workers in the intervention group were included in the analysis if they completed at least 2 months of supplementation to ensure adequate vitamin D levels. The primary analysis compared the incidence rate of all ILI, while secondary analyses examined incidence rates of COVID-19 ILI and non-COVID-19 ILI. Between October 2020 and November 2021, 255 healthcare workers (age 47 ± 12 years, 199 women) completed at least two months of vitamin D3 supplementation. The control group consisted of 2827 workers. Vitamin D3 5000 IU supplementation was associated with a lower risk of ILI (incidence rate difference: -1.7 × 10-4/person-day, 95%-CI: -3.0 × 10-4 to -3.3 × 10-5/person-day, p = 0.015) and a lower incidence rate for non-COVID-19 ILI (incidence rate difference: -1.3 × 10-4/person-day, 95%-CI -2.5 × 10-4 to -7.1 × 10-6/person-day, p = 0.038). COVID-19 ILI incidence was not statistically different (incidence rate difference: -4.2 × 10-5/person-day, 95%-CI: -10.0 × 10-5 to 1.5 × 10-5/person-day, p = 0.152). Daily supplementation with 5000 IU vitamin D3 reduces influenza-like illness in healthcare workers.
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Lam MB, Friend TH, Erfani P, Orav EJ, Jha AK, Figueroa JF. ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study. J Gen Intern Med 2022; 37:3275-3282. [PMID: 35022958 PMCID: PMC9550919 DOI: 10.1007/s11606-021-07183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN Retrospective analysis of Medicare claims. PATIENTS We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.
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Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, MA, Boston, USA.
| | - Tynan H Friend
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- School of Public Health, Brown University, Providence, RI, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, MA, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Implementing advance care planning in heart failure: a qualitative study of primary healthcare professionals. Br J Gen Pract 2021; 71:e550-e560. [PMID: 33947665 PMCID: PMC8103928 DOI: 10.3399/bjgp.2020.0973] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/19/2021] [Indexed: 02/06/2023] Open
Abstract
Background Advance care planning (ACP) can improve the quality of life of patients suffering from heart failure (HF). However, primary care healthcare professionals (HCPs) find ACP difficult to engage with and patient care remains suboptimal. Aim To explore the views of primary care HCPs on how to improve their engagement with ACP in HF. Design and setting A qualitative interview study with GPs and primary care nurses in England. Method Semi-structured interviews were conducted with a purposive sample of 24 primary care HCPs. Data were analysed using reflexive thematic analysis. Results Three main themes were constructed from the data: ACP as integral to holistic care in HF; potentially limiting factors to the doctor–patient relationship; and approaches to improve professional performance. Many HCPs saw the benefits of ACP as synonymous with providing holistic care and improving patients’ quality of life. However, some feared that initiating ACP could irrevocably damage their doctor–patient relationship. Their own fear of death and dying, a lack of disease-specific communication skills, and uncertainty about the right timing were significant barriers to ACP. To optimise their engagement with ACP in HF, HCPs recommended better clinician–patient dialogue through question prompts, enhanced shared decision-making approaches, synchronising ACP across medical specialties, and disease-specific training. Conclusion GPs and primary care nurses are vital to deliver ACP for patients suffering from HF. HCPs highlighted important areas to improve their practice and the urgent need for investigations into better clinician–patient engagement with ACP.
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Gabbard J, Pajewski NM, Callahan KE, Dharod A, Foley KL, Ferris K, Moses A, Willard J, Williamson JD. Effectiveness of a Nurse-Led Multidisciplinary Intervention vs Usual Care on Advance Care Planning for Vulnerable Older Adults in an Accountable Care Organization: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:361-369. [PMID: 33427851 PMCID: PMC7802005 DOI: 10.1001/jamainternmed.2020.5950] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Advance care planning (ACP), especially among vulnerable older adults, remains underused in primary care. Additionally, many ACP initiatives fail to integrate directly into the electronic health record (EHR), resulting in infrequent and disorganized documentation. OBJECTIVE To determine whether a nurse navigator-led ACP pathway combined with a health care professional-facing EHR interface improves the occurrence of ACP discussions and their documentation within the EHR. DESIGN, SETTING, AND PARTICIPANTS This was a randomized effectiveness trial using the Zelen design, in which patients are randomized prior to informed consent, with only those randomized to the intervention subsequently approached to provide informed consent. Randomization began November 1, 2018, and follow-up concluded November 1, 2019. The study population included patients 65 years or older with multimorbidity combined with either cognitive or physical impairments, and/or frailty, assessed from 8 primary care practices in North Carolina. INTERVENTIONS Participants were randomized to either a nurse navigator-led ACP pathway (n = 379) or usual care (n = 380). MAIN OUTCOMES AND MEASURES The primary outcome was documentation of a new ACP discussion within the EHR. Secondary outcomes included the usage of ACP billing codes, designation of a surrogate decision maker, and ACP legal form documentation. Exploratory outcomes included incident health care use. RESULTS Among 759 randomized patients (mean age 77.7 years, 455 women [59.9%]), the nurse navigator-led ACP pathway resulted in a higher rate of ACP documentation (42.2% vs 3.7%, P < .001) as compared with usual care. The ACP billing codes were used more frequently for patients randomized to the nurse navigator-led ACP pathway (25.3% vs 1.3%, P < .001). Patients randomized to the nurse navigator-led ACP pathway more frequently designated a surrogate decision maker (64% vs 35%, P < .001) and completed ACP legal forms (24.3% vs 10.0%, P < .001). During follow-up, the incidence of emergency department visits and inpatient hospitalizations was similar between the randomized groups (hazard ratio, 1.17; 95% CI, 0.92-1.50). CONCLUSIONS AND RELEVANCE A nurse navigator-led ACP pathway integrated with a health care professional-facing EHR interface increased the frequency of ACP discussions and their documentation. Additional research will be required to evaluate whether increased EHR documentation leads to improvements in goal-concordant care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03609658.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M Pajewski
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ajay Dharod
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Section on General Internal Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kristie L Foley
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Keren Ferris
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adam Moses
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Willard
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
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