Impact of an Advance Care Planning Video Intervention on Care of Short‐Stay Nursing Home Patients

Abstract

BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short‐stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. PARTICIPANTS A total of 2,538 and 5,290 short‐stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short‐stay patients without advanced illness in the intervention and control arms, respectively. INTERVENTION Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. MEASUREMENTS Follow‐up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person‐days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube‐feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. RESULTS There was no significant reduction in hospital transfers per 1000 person‐days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6–13.1) vs 13.2 (12.5–13.7); rate difference: −0.8; 95% CI = −1.8–0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person‐days alive in the intervention versus control among short‐stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short‐stay patients with and without advanced illness were shown videos, respectively. CONCLUSION An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short‐stay NH patients; however, fidelity to the intervention was low.

What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials

“…This outcome was assessed by 22 RCTs 24 25 33–35 37 41 42 54 57 66 68 69 109–117. Of these four (18%) RCTs68 109–111 showed significantly reduced healthcare use/costs.…”

Postacute care outcomes in home health or skilled nursing facilities in patients with a diagnosis of dementia

“…Third, improved advanced care planning around the hospital to postacute care transition is needed to avoid postacute care stays that are more consistent with harm than benefit 13 . Risk prediction scores have been developed to identify patients at high risk for adverse outcomes in SNF and HH, and several advanced care planning interventions in SNF are being tested in trials 30–34 . However, these efforts may be occurring too late in the care trajectory (e.g., once the patient is already in SNF).…”

The Effectiveness of Video Decision Aid on Advance Care Planning With Adult Patients

“…Mitchell et al 26 and Loomer et al 23 found no effect on hospital transfers per 1000 person-days alive for nursing home residents with long stay (>100 days) and short stay (<100 days). Two RCTs 23,26 reported on transfers and hospitalizations. Midquality evidence (rated down for imprecision) suggests no significant reduction in hospital transfers (RR, 1.00; 95% CI, 0.99-1.02; I 2 = 48%; heterogeneity P = .17; Supplemental Appendix 2, Figure 9, http://links.lww.com/JHPN/A91; P = .71).…”

“…Three RCTs 19,24,27 were ranked as high-quality studies. Allocation concealment was high risk in 7 14,17,18,[20][21][22][23] RCTs and unclear in 1 RCT. 25 Blinding of participants and personnel was high risk in 2 RCTs 15,23 and unclear in 1 RCT, 16 and blinding of outcome assessment was high risk in 5 RCTs 14,18,[20][21][22] and unclear in 2 RCTs.…”