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Green AR, Quiles R, Daddato AE, Merrey J, Weffald L, Gleason K, Xue QL, Swarthout M, Feeser S, Boyd CM, Wolff JL, Blinka MD, Libby AM, Boxer RS. Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study. J Am Geriatr Soc 2024. [PMID: 38488757 DOI: 10.1111/jgs.18867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed. METHODS A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS). RESULTS 69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control. CONCLUSION Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rosalphie Quiles
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrea E Daddato
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
| | | | - Linda Weffald
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Kathy Gleason
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
| | - Qian-Li Xue
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Scott Feeser
- Johns Hopkins Community Physicians, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marcela D Blinka
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anne M Libby
- Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rebecca S Boxer
- Davis Department of Medicine, University of California, Sacramento, California, USA
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Colburn JL, Scerpella DL, Chapin M, Walker KA, Dy SM, Saylor MA, Sharma N, Rebala S, Anderson RE, McGuire M, Hussain N, Rawlinson C, Cotter V, Cockey K, Roth DL, Nicholson KLC, Giovannetti ER, Sancho MB, Echavarria D, Boyd CM, Wolff JL, Smith KM. SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention. J Pain Symptom Manage 2023; 66:e255-e264. [PMID: 37100306 DOI: 10.1016/j.jpainsymman.2023.04.014] [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: 12/30/2022] [Revised: 03/24/2023] [Accepted: 04/08/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Few advance care planning (ACP) interventions have been scaled in primary care. PROBLEM Best practices for delivering ACP at scale in primary care do not exist and prior efforts have excluded older adults with Alzheimer's Disease and Related Dementias (ADRD). INTERVENTION SHARING Choices (NCT#04819191) is a multicomponent cluster-randomized pragmatic trial conducted at 55 primary care practices from two care delivery systems in the Mid-Atlantic region of the U.S. We describe the process of implementing SHARING Choices within 19 practices randomized to the intervention, summarize fidelity to planned implementation, and discuss lessons learned. OUTCOMES Embedding SHARING Choices involved engagement with organizational and clinic-level partners. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 1215 conversations occurred. Most conversations (94.8%) were less than 45 minutes duration. Just 13.1% of ACP conversations included family. Patients with ADRD comprised a small proportion of patients who engaged in ACP. Implementation adaptations included transitioning to remote modalities, aligning ACP outreach with the Medicare Annual Wellness Visit, accommodating primary care practice flexibility. LESSONS LEARNED Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with practice staff; adapting implementation processes to fit the unique needs of two health systems; and modifying efforts to meet health system goals and priorities.
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Affiliation(s)
- Jessica L Colburn
- Division of Geriatric Medicine & Gerontology (JLC, CMB), Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Daniel L Scerpella
- Department of Health Policy and Management (DLS, DE, JLW), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Margo Chapin
- Johns Hopkins University (MC), Baltimore, MD, USA
| | - Kathryn A Walker
- Palliative Care (KAW, SMD, KC), MedStar Health, Columbia, MD, USA
| | - Sydney M Dy
- Palliative Care (KAW, SMD, KC), MedStar Health, Columbia, MD, USA
| | | | | | - Sri Rebala
- MedStar Health (NS, SR), Columbia, MD, USA
| | - Ryan E Anderson
- Clinical Care Transformation (REA, ERQ), MedStar Health, Columbia, MD, USA
| | - Maura McGuire
- Johns Hopkins Community Physicians (MM), Baltimore, MD, USA
| | - Naaz Hussain
- Johns Hopkins Community Physicians (NH, CR), Frederick, MD, USA
| | | | - Valerie Cotter
- Johns Hopkins School of Nursing (MAS, VC), Baltimore, MD, USA
| | - Kimberly Cockey
- Palliative Care (KAW, SMD, KC), MedStar Health, Columbia, MD, USA
| | - David L Roth
- Division of Geriatric Medicine and Gerontology (DLR), Center on Aging and Health, Baltimore, MD, USA
| | | | | | - Marcella B Sancho
- JHCP Mt. Washington Campus - Marbury Building (MBS), Baltimore, MD, USA
| | - Diane Echavarria
- Department of Health Policy and Management (DLS, DE, JLW), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine & Gerontology (JLC, CMB), Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management (DLS, DE, JLW), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kelly M Smith
- MedStar Health Institute for Quality and Safety (KMS), MedStar Health, Columbia, MD, USA
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Wolff JL, Cagle J, Echavarria D, Dy SM, Giovannetti ER, Boyd CM, Hanna V, Hussain N, Reiff JS, Scerpella D, Zhang T, Roth DL. Sharing Health Care Wishes in Primary Care (SHARE) among older adults with possible cognitive impairment in primary care: Study protocol for a randomized controlled trial. Contemp Clin Trials 2023; 129:107208. [PMID: 37116645 PMCID: PMC10258688 DOI: 10.1016/j.cct.2023.107208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Little is known about effective strategies to improve advance care planning (ACP) for persons with cognitive impairment in primary care, the most common setting of care. We describe a randomized controlled trial to test the efficacy of a multicomponent communication intervention, "Sharing Healthcare Wishes in Primary Care" (SHARE). PARTICIPANTS Planned enrollment of 248 dyads of adults 80 years and older with possible cognitive impairment and their care partner, from primary care clinics at 2 Mid-Atlantic health systems. METHODS The treatment protocol encompasses an introductory letter from the clinic; access to a designated facilitator trained in ACP; person-family agenda-setting to align perspectives about the family's role; and print education. The control protocol encompasses minimally enhanced usual care, which includes print education and a blank advance directive. Randomization occurs at the individual dyad-level. Patient and care partner surveys are fielded at baseline, 6-, 12-, and 24- months. Fidelity of interventionist delivery of the protocol is measured through audio-recordings of ACP conversations and post-meeting reports, and by ongoing monitoring and support of interventionists. OUTCOMES The primary outcome is quality of end-of-life care communication at 6 months; secondary outcomes include ACP process measures. An exploratory aim examines end-of-life care quality and bereaved care partner experiences for patients who die by 24 months. CONCLUSIONS Caregiver burden, clinician barriers, and impaired decisional capacity amplify the difficulty and importance of ACP discussions in the context of cognitive impairment: this intervention will comprehensively examine communication processes for this special subpopulation in a key setting of primary care. REGISTRATION ClinicalTrials.gov: NCT04593472.
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Affiliation(s)
- Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
| | - John Cagle
- School of Social Work, University of Maryland, Baltimore, Baltimore, MD, United States of America.
| | - Diane Echavarria
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, United States of America.
| | - Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, United States of America.
| | - Erin R Giovannetti
- Health Economics and Aging Research Institute, MedStar Health, 10980 Grantchester Way Columbia, MD 21044, United States of America.
| | - Cynthia M Boyd
- Division of Geriatric Medicine & Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building, Center Tower, Room 317, Baltimore, MD 21224, United States of America.
| | - Valecia Hanna
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, United States of America.
| | - Naaz Hussain
- Johns Hopkins Community Physicians, 45 TJ Drive, Suite 109, Frederick, MD 21702, United States of America.
| | - Jenni S Reiff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
| | - Danny Scerpella
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, United States of America.
| | - Talan Zhang
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, United States of America.
| | - David L Roth
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD, United States of America.
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Dassel KB, Iacob E, Utz RL, Supiano KP, Fuhrmann H. Promoting Advance Care Planning for Persons with Dementia: Study Protocol for the LEAD (Life-Planning in Early Alzheimer's and Other Dementias) Clinical Trial. OBM INTEGRATIVE AND COMPLIMENTARY MEDICINE 2023; 8:26. [PMID: 37859668 PMCID: PMC10586385 DOI: 10.21926/obm.icm.2301004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Due to the insidious progression of Alzheimer's disease and related dementias (ADRD), surrogate decision-makers typically make medical and long-term-care decisions for a care recipient, most often a family care partner. Unfortunately, many care recipient/care partner dyads have failed to engage in advance care planning or have lost the opportunity to do so due to the cognitive decline of the care recipient. To address this need, our team created a validated dementia-focused advance care planning tool known as the LEAD Guide (Life-Planning in Early Alzheimer's and Other Dementias). With funding from the National Alzheimer's Association and in consultation with our community advisory board, we developed a preliminary web-based intervention. This intervention integrates the LEAD Guide with self-paced educational modules that lead dyads through conversations and dementia-focused advance care planning processes. In this concept paper, we describe the aims of our funded R01 clinical trial (National Institute on Aging), where we aim to refine our preliminary web-based platform for use in a 5-month mixed-method NIH Stage-1 behavioral intervention. Using a sample of diverse community-based ADRD dyads (n = 60), we aim to: 1) describe the acceptability, usability, and feasibility of the intervention, 2) assess the initial efficacy of the intervention on the primary outcome (decision-making self-efficacy), and secondary outcomes (relationship quality, subjective well-being, anxiety) as perceived by both the care recipient and the care partner, and 3) examine advance care planning congruence as a mechanism of action. The LEAD clinical trial addresses public health challenges by guiding and supporting families through challenging advance care planning conversations, facilitating the transfer of knowledge regarding care preferences and values from the care recipient to the care partner, with the ultimate goal of improving the quality of life for both individuals with ADRD and their care partners.
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Affiliation(s)
- Kara B. Dassel
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| | - Eli Iacob
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
| | - Rebecca L. Utz
- University of Utah, College of Social and Behavioral Sciences, 260 South Central Campus Drive, Salt Lake City, UT, USA
| | | | - Hollie Fuhrmann
- University of Utah, College of Nursing, 10 S. 2000 E., Salt Lake City, UT, USA
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SHARING Choices: Design and rationale for a pragmatic trial of an advance care planning intervention for older adults with and without dementia in primary care. Contemp Clin Trials 2022; 119:106818. [PMID: 35690262 DOI: 10.1016/j.cct.2022.106818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/27/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Advance care planning (ACP) and involving family are particularly important in dementia, and primary care is a key setting. The purpose of this trial is to examine the impact and implementation of SHARING Choices, an intervention to improve communication for older adults with and without dementia through proactively supporting ACP and family engagement in primary care. METHODS We cluster-randomized 55 diverse primary care practices across two health systems to the intervention or usual care. SHARING Choices is a multicomponent intervention that aims to improve communication through patient and family engagement in ACP, agenda setting, and shared access to the patient portal for all patients over 65 years of age. The primary outcomes include documentation of an advance directive or medical orders for life-sustaining treatment in the electronic health record (EHR) at 12 months for all patients and receipt of potentially burdensome care within 6 months of death for the subgroup of patients with serious illness. We plan a priori sub-analysis for patients with dementia. Data sources include the health system EHRs and the Maryland health information exchange. We use a mixed-methods approach to evaluate uptake, fidelity and adaptation of the intervention and implementation facilitators and barriers. CONCLUSIONS This cluster-randomized pragmatic trial examines ACP with a focus on the key population of those with dementia, implementation in diverse settings and innovative approaches to trial design and outcome abstraction. Mixed-methods approaches enable understanding of intervention delivery and facilitators and barriers to implementation in rapidly changing health care systems. CLINICALTRIALS gov Identifier: NCT04819191.
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Smith KM, Scerpella D, Guo A, Hussain N, Colburn JL, Cotter VT, Aufill J, Dy SM, Wolff JL. Perceived Barriers and Facilitators of Implementing a Multicomponent Intervention to Improve Communication With Older Adults With and Without Dementia (SHARING Choices) in Primary Care: A Qualitative Study. J Prim Care Community Health 2022; 13:21501319221137251. [PMID: 36398937 PMCID: PMC9677296 DOI: 10.1177/21501319221137251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Implementing patient- and family-centered communication strategies has proven challenging in primary care, particularly for persons with dementia. To address this, we designed SHARING Choices, a multicomponent intervention combining patient and family partnered agenda setting, electronic portal access, and supports for advance care planning (ACP). This qualitative descriptive study describes factors affecting SHARING Choices implementation within primary care. METHODS Semi-structured interviews or focus groups with patient/family dyads (family, friends, unpaid caregivers) and primary care stakeholders (clinicians, staff, administrators) elicited perceived barriers and facilitators of SHARING Choices implementation. Field notes and interview transcripts were coded using template analysis along the Consolidated Framework for Implementation Research (CFIR) constructs. Content analysis identified themes not readily categorized within CFIR. RESULTS About 22 dyads, including 14 with cognitive impairment, and 30 stakeholders participated in the study. Participants were receptive to the SHARING Choices components. Enablers of SHARING Choices included adaptability of the intervention, purposive engagement of family (particularly for patients with dementia), consistency with organizational priorities, and the relative advantage of SHARING Choices compared to current practices. Perceived barriers to implementation included intervention complexity, space constraints, workflow, and ACP hesitancy. The ACP facilitator was perceived as supportive in addressing individual and organizational implementation barriers including patient health and technology literacy and clinician time for ACP discussions. CONCLUSIONS Patients, family, and primary care clinicians endorsed the objectives and individual components of SHARING Choices. Strategies to enhance adoption were to simplify materials, streamline processes, leverage existing workflows, and embed ACP facilitators within the primary care team.
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Affiliation(s)
- Kelly M Smith
- Michael Garron Hospital - Toronto East Health Network, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Danny Scerpella
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy Guo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | - Jennifer Aufill
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sydney M Dy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer L Wolff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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