Impact of a prospective feedback loop on care review activities in older patients at the end of life. A stepped-wedge randomised trial

Prevalence of Value-Based Care for Older People with Dementia Likely to Be Nearing End of Life: A Hospital Retrospective Cohort

Background: Patients with dementia (PwD) nearing end of life (nEOL) do not always receive optimal end-of-life care, including timely specialist palliative care input. In hospitalized PwD likely to be nEOL, we aimed to determine the prevalence of goals of care discussions; the incidence and timing of referral to palliative care; factors associated with palliative care referral and timely (within 2 days) palliative care referral; and the prevalence of polypharmacy (>5 medications) and in-hospital deprescribing (cessation). Methods: A retrospective chart review of a cohort of PwD admitted under geriatric medicine 1 July 2021-30 June 2022 was conducted, screening to identify nEOL status. Results: A total of 298 patients (mean age of 83.5 [SD 7.4] and 51.3% females) were included in the final analysis. Eleven percent of eligible patients (33/298) died during admission. Overall, 80.9% had discussed an advance care plan (ACP). The mean time from admission to the discussion of an ACP was 1 day (SD = 5.02). One in twenty (5.4%) had their goals of care revised during admission, with 15 transitioning to palliation. Only 7.1% were referred to palliative care during admission. The mean time to referral was 9.8 days (SD 7.3; range 0-26). One in fourteen (7.4%) were discharged from hospital on an end-of-life pathway. In multivariable analysis, both the clinical frailty score (CFS) (aOR per unit increase 3.66; 95%CI 1.65-8.09, p = 0.001) and meeting ≥ 2 deterioration criteria (per CriSTAL tool) (OR 3.68; 95% CI 1.07-12.70, p = 0.039) were independently associated with referral to palliative care. Polypharmacy was common at admission (76.2%), with a mean number of medications of 8.4 (SD = 4). The median number of medications ceased during admission was two (IQR 0-4). Conclusions: Contrary to our hypothesis, we found a high quality of care of PwD likely nEOL, reflected by frequent ACPs in hospital, but it fell short of palliative care specialist input. Polypharmacy on admission and discharge may be further improved by aligning medication use with goals of care among PwD approaching the end of life, and considering the hospital nurse-driven identification of practice gaps is encouraged.

The conveyor belt for older people nearing the end of life

The current fallback position for the elderly frail nearing the end of life (less than 12 months to live) is hospitalisation. There is a reluctance to use the term 'terminally ill' for this population, resulting in overtreatment, overdiagnosis and management that is not consistent with the wishes of people. This is the major contributor to the so-called hospital crisis, including decreased capacity of hospitals, reduced ability to conduct elective surgery, increased attendances at emergency departments and ambulance ramping. The authors recently conducted the largest randomised study, to their knowledge, attempting to inform specialist hospital medical teams about the terminally ill status of their admitted patients. This information did not influence their clinical decisions in any way. The authors discuss the reasons why this may have occurred, such as the current avoidance of discussing death and dying by society and the concentration of healthcare workers on actively managing the acute presenting problem and ignoring the underlying prognosis in the elderly frail. The authors discuss ways of improving the management of the elderly nearing the end of life, such as more detailed goals of care discussions using the concept of shared decision-making rather than simply completing Advanced Care Decision documents. Empowering people in this way could become the most important driver of people's health care.

Impact of a prospective feedback loop aimed at reducing non-beneficial treatments in older people admitted to hospital and potentially nearing the end of life. A cluster stepped-wedge randomised controlled trial

OBJECTIVES

To investigate if a prospective feedback loop that flags older patients at risk of death can reduce non-beneficial treatment at end of life.

DESIGN

Prospective stepped-wedge cluster randomised trial with usual care and intervention phases.

SETTING

Three large tertiary public hospitals in south-east Queensland, Australia.

PARTICIPANTS

14 clinical teams were recruited across the three hospitals. Teams were recruited based on a consistent history of admitting patients aged 75+ years, and needed a nominated lead specialist consultant. Under the care of these teams, there were 4,268 patients (median age 84 years) who were potentially near the end of life and flagged at risk of non-beneficial treatment.

INTERVENTION

The intervention notified clinicians of patients under their care determined as at-risk of non-beneficial treatment. There were two notification flags: a real-time notification and an email sent to clinicians about the at-risk patients at the end of each screening day. The nudge intervention ran for 16-35 weeks across the three hospitals.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients with one or more intensive care unit (ICU) admissions. The secondary outcomes examined times from patients being flagged at-risk.

RESULTS

There was no improvement in the primary outcome of reduced ICU admissions (mean probability difference [intervention minus usual care] = -0.01, 95% confidence interval -0.08 to 0.01). There were no differences for the times to death, discharge, or medical emergency call. There was a reduction in the probability of re-admission to hospital during the intervention phase (mean probability difference -0.08, 95% confidence interval -0.13 to -0.03).

CONCLUSIONS

This nudge intervention was not sufficient to reduce the trial's non-beneficial treatment outcomes in older hospital patients.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).

Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life

BACKGROUND

Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention.

METHODS

Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed.

RESULTS

Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level.

CONCLUSIONS

An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).