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

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.

Reaching Ambulatory Older Adults with Educational Tools: Comparative Efficacy and Cost of Varied Outreach Modalities in Primary Care

BACKGROUND

Providing patients with access to health information that can be obtained outside of an office visit is an important part of education, yet little is known about the effectiveness of outreach modalities to connect older adults to online educational tools. The objective was to identify the effectiveness and cost of outreach modalities providing online information about advance care planning (ACP) for older adults.

METHODS

Six different outreach modalities were utilized to connect patients to online educational tools (ACP video decision aids). Participants were 13,582 patients aged 65 and older of 185 primary care providers with appointments over a 30-month period within a large health system in the greater New York City area. Main outcome measures were number of online video views and costs per outreach for each modality.

KEY RESULTS

There were 1150 video views for 21,407 remote outreach events. Text messages, sent to the largest volume of patients (8869), had the highest outcome rate (9.6%) and were the most economical ($0.09). Characterization of phone calls demonstrated 21.7% engagement in the topic of ACP but resulted in minimal video views (<1%) and incurred the highest cost per outreach ($2.88). In-office handouts had negligible results (<1%).

CONCLUSIONS

Text was the most cost-effective modality to connect older adults to an online educational tool in this pragmatic trial, though overall efficacy of all modalities was low.

PSAT231 Perceived Cognitive Function Is Associated With Adherence to Diabetes Self-Management Behaviors Among Breast Cancer Survivors

Introduction

In the United States, the annual incidence of breast cancer and comorbid type 2 diabetes mellitus (T2DM) in women is ∼40,000. Both conditions are associated with cognitive decline, which adversely affects self-management behaviors (SMBs) including adherence to medication, dietary and exercise recommendations. Patients with breast cancer also self-report decreased cognitive ability. Such perceptions can result from objective decline in cognitive function as well as factors such as anxiety and depression. Yet, the effect of perceived cognitive function on diabetes SMBs remains unclear. We evaluated the relationship between perceived cognitive function and adherence to SMBs in breast cancer survivors with T2DM.

Hypothesis

Greater adherence to diabetes SMBs will be associated with higher perceived cognitive function.

Methodology

We enrolled women ≥ 55 years with pre-existing T2DM who were diagnosed with Stage 0-IIIA breast cancer in the past 15 years, had completed adjuvant chemotherapy and/or prescribed hormonal therapy, and were taking ≥ 1 oral diabetes medication. We measured perceived cognitive function with the Functional Assessment of Cancer Therapy-Cognition (FACT-Cog, version 3) and diabetes SMBs adherence with the Summary of Diabetes Self Care Activities (SDSCA) questionnaire. Adherence to diabetes medications was assessed using an electronic monitoring bottlecap (eCAP). Data were dichotomized into adherent vs non-adherent. Wilcoxon rank-sum tests were used to compare cognition scores between groups.

Results

239 patients (mean age: 66.5 years; 28% Black, 39% white, 6% Asian, 7% other, 20% unanswered) completed interviews. Cancer survivors who were non-adherent with their diabetes medication perceived themselves as having lower cognitive function (Total FACT-Cog median (interquartile range; IQR) 102 (36.7) vs. 115 (30), p< 0.05), with lower scores on the perceived cognitive ability and impact of cognitive impairments on quality of life (QOL) subscales (Cognitive-ability median (IQR) 20 (9) vs. 23 (7), p< 0.001; QOL median (IQR) 13 (6) vs 16 (3), p< 0.05). Similarly, those who reported healthy eating for <5 days over the past week and <5 days/week over the past month had lower cognitive self-perception scores (Total FACT-Cog median (IQR) 106 (37) vs. 114 (25), p< 0.05 and 106 (37) vs. 114 (26), p< 0.001 respectively), and significantly differed on the perceived cognitive impairment and comments from others subscales (Cognitive-impairment median (IQR) 55.1 (26) vs. 62 (17), p< 0.01 and 54.5 (25) vs. 62 (17), p< 0.001; Comments median (IQR) 16 (2) vs. 16 (1), p< 0.05 and 16 (2) vs. 16 (1), p< 0.001). Adherence to exercise and to blood glucose testing were not associated with differences in perceived cognitive function.

Conclusion

Among breast cancer survivors with T2DM, adherence to diet and medication was associated with greater self-perceptions of cognitive function. Future studies will test whether interventions to improve patients’ perceptions of their cognitive abilities can influence self-care.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital

INTRODUCTION

Despite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer's disease and related Dementias, regardless of age.

METHODS AND ANALYSIS

The Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included.

ETHICS AND DISSEMINATION

The Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT04857060; ClinicalTrials.gov.

MON-LB306 Association Between Cancer Related Beliefs and Diabetes Medication Adherence Among Breast Cancer Survivors With Comorbid Type 2 Diabetes

Introduction: Cancer and diabetes mellitus (DM) are leading causes of death in the United States. Each year, over 245,000 women are diagnosed with breast cancer, and approximately 18% of patients diagnosed have preexisting DM. The presence of a comorbidity, such as DM increases women’s mortality risk by 40%. While studies have shown decreased adherence to hypoglycemic medications after cancer diagnosis, the effect of cancer related beliefs on DM medication adherence has not been fully explored. In this study, we evaluated the association between cancer related beliefs and DM medication adherence in survivors of breast cancer.

Hypothesis: Patients with greater positive beliefs about cancer (including personal control, treatment control and understanding) would exhibit greater adherence to DM medication.

Methodology: We enrolled women >55 years with Stage 0-IIIA breast cancer diagnosed in the past 10 years, who had completed chemotherapy and/or were prescribed hormonal therapy and had pre-existing type 2 DM treated with at least 1 oral DM medication. Cancer related beliefs were assessed using the Illness Perception Questionnaire (IPQ). Medication adherence was evaluated using the Medication Adherence Rating Scale (MARS). Adherence was dichotomized at a mean MARS score of ≥4.5. Wilcoxon rank-sum tests were used to examine the relationship between patients’ cancer related beliefs and DM medication adherence.

Results: Thus far, 108 women have completed baseline surveys. Of these participants, 37% were black, 31% white, 14% Hispanic, 6.5% Asian, and 8.3% other. The mean age was 65 years. Cancer survivors who were adherent to DM medication had a greater sense of personal control over their cancer (median score 22.0 vs. 19.0, p<0.001) and endorsed a better understanding of their cancer (median score 20.0 vs. 14.0, p=0.03). No associations were seen between beliefs about the duration and consequences of cancer and DM medication adherence.

Conclusion: Among breast cancer survivors with comorbid DM, having a greater sense of control over and understanding of cancer was associated with DM medication adherence. Working with breast cancer survivors to increase their perceived control over and understanding of their cancer may help improve adherence to DM medication.