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Original Investigation
July 6, 2020

Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents: A Pragmatic Cluster Randomized Clinical Trial

Author Affiliations
  • 1Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
  • 2Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 3Section of General Medicine, Massachusetts General Hospital, Boston
  • 4Harvard Medical School, Boston, Massachusetts
  • 5Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
  • 6Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
  • 7Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
JAMA Intern Med. 2020;180(8):1070-1078. doi:10.1001/jamainternmed.2020.2366
Key Points

Question  Can an advance care planning video program embedded in nursing home health care systems affect hospital transfers, burdensome treatments, and hospice enrollment among residents with and without advanced illness?

Findings  In this pragmatic cluster randomized clinical trial of 12 479 residents with advanced illness, hospital transfers, burdensome treatments, and hospice enrollment did not significantly differ between the video intervention and control group. Intervention fidelity was low and variable across facilities.

Meaning  An advance care planning video program did not significantly affect hospital transfers, burdensome treatments, or hospice enrollment among residents with and without advanced illness; low intervention fidelity underscores implementation challenges in this setting.

Abstract

Importance  Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking.

Objective  To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness.

Design, Setting, and Participants  The Pragmatic Trial of Video Education in Nursing Homes was a pragmatic cluster randomized clinical trial conducted between February 1, 2016, and May 31, 2019, at 360 nursing homes (119 intervention and 241 control) in 32 states owned by 2 for-profit corporations. Participants included 4171 long-stay residents with advanced dementia or cardiopulmonary disease (hereafter referred to as advanced illness) in the intervention group and 8308 long-stay residents with advanced illness in the control group, 5764 long-stay residents without advanced illness in the intervention group, and 11 773 long-stay residents without advanced illness in the control group. Analyses followed the intention-to-treat principle.

Interventions  Five 6- to 10-minute ACP videos were made available on tablet computers or online. Designated champions (mostly social workers) in intervention facilities were instructed to offer residents (or their proxies) the opportunity to view a video(s) on admission and every 6 months. Control facilities used usual ACP practices.

Main Outcomes and Measures  Twelve-month outcomes were measured for each resident. The primary outcome was hospital transfers per 1000 person-days alive in the advanced illness cohort. Secondary outcomes included the proportion of residents with or without advanced illness experiencing 1 or more hospital transfer, 1 or more burdensome treatment, and hospice enrollment. To monitor fidelity, champions completed reports in the electronic record whenever they offered to show residents a video.

Results  The study included 4171 long-stay residents with advanced illness in the intervention group (2970 women [71.2%]; mean [SD] age, 83.6 [9.1] years), and 8308 long-stay residents with advanced illness in the control group (5857 women [70.5%]; mean [SD] age, 83.6 [8.9] years), 5764 long-stay residents without advanced illness in the intervention group (3692 women [64.1%]; mean [SD] age, 81.5 [9.2] years), and 11 773 long-stay residents without advanced illness in the control group (7467 women [63.4%]; mean [SD] age, 81.3 [9.2] years). There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention vs control groups (rate [SE], 3.7 [0.2]; 95% CI, 3.4-4.0 vs 3.9 [0.3]; 95% CI, 3.6-4.1; rate difference [SE], −0.2 [0.3]; 95% CI, −0.5 to 0.2). Secondary outcomes did not significantly differ between trial groups among residents with and without advanced illness. Based on champions’ reports, 912 of 4171 residents with advanced illness (21.9%) viewed ACP videos. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities [11.8%]) to more than 40% (22 facilities [18.5%]).

Conclusions and Relevance  This study found that an ACP video program was not effective in reducing hospital transfers, decreasing burdensome treatment use, or increasing hospice enrollment among long-stay residents with or without advanced illness. Intervention fidelity was low, highlighting the challenges of implementing new programs in nursing homes.

Trial Registration  ClinicalTrials.gov Identifier: NCT02612688

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