Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults

Volandes, Angelo E.; Zupanc, Sophia N.; Lakin, Joshua R.; Chang, Yuchiao; Burns, Edith; LaVine, Nancy; Carney, Maria; Martins-Welch, Diana; Emmert, Kaitlin; Itty, Jennifer; Moseley, Edward T.; Davis, Aretha Delight; El‐Jawahri, Areej; Gundersen, Daniel A.; Fix, Gemmae M.; Yacoub, Andrea M.; Schwartz, Peter H.; Gabry-Kalikow, Shira; Garde, Cynthia; Fischer, Jonathan; Henault, Lori; Burgess, L.; Goldman, Julie; Kwok, Anne; Singh, Navdeep; Suarez, Armando L. Alvarez; Gromova, Valeria; Jacome, Sonia; Tulsky, James A.

doi:10.1001/jamanetworkopen.2022.0354

Cited by 22 publications

(35 citation statements)

References 33 publications

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“…The primary outcome of this trial is documentation of a goals-of-care conversation in the EHR at any time during the index hospitalisation, as ascertained by NLP-assisted review of clinical notes accumulated during that hospitalisation. Similar to our previous studies, documentation that will count towards the outcome will include a discussion with the patient regarding limitations of life-sustaining treatment, palliative care, hospice, goals-of-care, time-limited trial or surrogate decision-makers 43 54. One secondary outcome of the trial is EHR documentation reflecting the presence and content of treatment preferences relating to resuscitation, feeding tubes and dialysis.…”

Section: Methodsmentioning

confidence: 97%

“…PCEs will receive Vital Talk intensive communication skills training via a highly structured series of Zoom conferences. 43 Additionally, the PCEs will engage in monthly coaching calls with two serious illness communication experts. Coaching calls will be designed to discuss and collectively debrief successes and challenges with clinical cases, identifying shared skills and language to deal with difficult patient situations.…”

Section: Methodsmentioning

confidence: 99%

“…Similar to our previous studies, documentation that will count towards the outcome will include a discussion with the patient regarding limitations of life-sustaining treatment, palliative care, hospice, goals-of-care, time-limited trial or surrogate decision-makers. 43 54 One secondary outcome of the trial is EHR documentation reflecting the presence and content of treatment preferences relating to resuscitation, feeding tubes and dialysis.…”

Section: Methodsmentioning

confidence: 99%

“…Data for both the primary outcome and secondary outcome related to resuscitation and treatment preferences will be obtained via NLP-assisted chart review as we have done in prior studies. 43 54–56 The clinical data ware house representative from each of the two sites will extract EHR data, including inpatient clinical notes, from eligible patients at the conclusion of each 2-month step period. A dedicated REDCap 57 database housed at Boston University (BU) will be used to enter caregiver survey data entry across both sites.…”

Section: Methodsmentioning

confidence: 99%

“…PCEs will receive Vital Talk intensive communication skills training via a highly structured series of Zoom conferences 43. Additionally, the PCEs will engage in monthly coaching calls with two serious illness communication experts.…”

Section: Methodsmentioning

confidence: 99%

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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

et al. 2022

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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

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Section: Methodsmentioning

confidence: 97%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 3 more Smart Citations

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

et al. 2022

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Intervention to Promote Communication About Goals of Care for Hospitalized Patients With Serious Illness

Curtis

Lee

Brumback

et al. 2023

JAMA

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ImportanceDiscussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness.ObjectiveTo evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness.Design, Setting, and ParticipantsA pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia.InterventionPhysicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions.Main Outcomes and MeasuresThe primary outcome was the proportion of patients with electronic health record–documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site.ResultsOf 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record–documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, −3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site.Conclusions and RelevanceAmong hospitalized older adults with serious illness, a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals-of-care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients.Trial RegistrationClinicalTrials.gov Identifier: NCT04281784

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Assessment of Natural Language Processing of Electronic Health Records to Measure Goals-of-Care Discussions as a Clinical Trial Outcome

et al. 2023

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ImportanceMany clinical trial outcomes are documented in free-text electronic health records (EHRs), making manual data collection costly and infeasible at scale. Natural language processing (NLP) is a promising approach for measuring such outcomes efficiently, but ignoring NLP-related misclassification may lead to underpowered studies.ObjectiveTo evaluate the performance, feasibility, and power implications of using NLP to measure the primary outcome of EHR-documented goals-of-care discussions in a pragmatic randomized clinical trial of a communication intervention.Design, Setting, and ParticipantsThis diagnostic study compared the performance, feasibility, and power implications of measuring EHR-documented goals-of-care discussions using 3 approaches: (1) deep-learning NLP, (2) NLP-screened human abstraction (manual verification of NLP-positive records), and (3) conventional manual abstraction. The study included hospitalized patients aged 55 years or older with serious illness enrolled between April 23, 2020, and March 26, 2021, in a pragmatic randomized clinical trial of a communication intervention in a multihospital US academic health system.Main Outcomes and MeasuresMain outcomes were natural language processing performance characteristics, human abstractor-hours, and misclassification-adjusted statistical power of methods of measuring clinician-documented goals-of-care discussions. Performance of NLP was evaluated with receiver operating characteristic (ROC) curves and precision-recall (PR) analyses and examined the effects of misclassification on power using mathematical substitution and Monte Carlo simulation.ResultsA total of 2512 trial participants (mean [SD] age, 71.7 [10.8] years; 1456 [58%] female) amassed 44 324 clinical notes during 30-day follow-up. In a validation sample of 159 participants, deep-learning NLP trained on a separate training data set from identified patients with documented goals-of-care discussions with moderate accuracy (maximal F1 score, 0.82; area under the ROC curve, 0.924; area under the PR curve, 0.879). Manual abstraction of the outcome from the trial data set would require an estimated 2000 abstractor-hours and would power the trial to detect a risk difference of 5.4% (assuming 33.5% control-arm prevalence, 80% power, and 2-sided α = .05). Measuring the outcome by NLP alone would power the trial to detect a risk difference of 7.6%. Measuring the outcome by NLP-screened human abstraction would require 34.3 abstractor-hours to achieve estimated sensitivity of 92.6% and would power the trial to detect a risk difference of 5.7%. Monte Carlo simulations corroborated misclassification-adjusted power calculations.Conclusions and RelevanceIn this diagnostic study, deep-learning NLP and NLP-screened human abstraction had favorable characteristics for measuring an EHR outcome at scale. Adjusted power calculations accurately quantified power loss from NLP-related misclassification, suggesting that incorporation of this approach into the design of studies using NLP would be beneficial.

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Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults

Cited by 22 publications

References 33 publications

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

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

Intervention to Promote Communication About Goals of Care for Hospitalized Patients With Serious Illness

Assessment of Natural Language Processing of Electronic Health Records to Measure Goals-of-Care Discussions as a Clinical Trial Outcome

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