A stepped-wedge randomised-controlled trial assessing the implementation, impact and costs of a prospective feedback loop to promote appropriate care and treatment for older patients in acute hospitals at the end of life: study protocol

Lee, Xing J.; Farrington, Alison; Carter, Hannah; Shield, Carla; Graves, Nicholas; McPhail, Steven; Harvey, Gill; White, Ben; Willmott, Lindy; Cardona, Magnolia; Hillman, Ken; Callaway, Leonie K.; Barnett, Adrian

doi:10.1186/s12877-020-01660-2

Cited by 4 publications

(3 citation statements)

References 42 publications

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“…The trial study design and analyses were pre-specified in a protocol [ 22 ], and the trial was pre-registered (ACTRN12619000675123).…”

Section: Methodsmentioning

confidence: 99%

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

White,

Barnett,

Lee

et al. 2024

Age and Ageing

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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).

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“…The trial study design and analyses were pre-specified in a protocol [ 22 ], and the trial was pre-registered (ACTRN12619000675123).…”

Section: Methodsmentioning

confidence: 99%

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

White,

Barnett,

Lee

et al. 2024

Age and Ageing

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“…Sites switch over from usual care to intervention sequentially in an order that is randomised before trial commencement. The InterACT protocol [ 19 ] and outcome papers [ 20 ] are published elsewhere.…”

Section: Introductionmentioning

confidence: 99%

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

Bracci,

Barnett,

Brown

et al. 2024

BMC Geriatr

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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).

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“…Here we present the results for three of the immediate impact measures of clinicians’ response to the intervention using the trial data currently available: clinician-led care review discussion; review of care directive measures; and palliative care referral. Other patient and cost outcomes analyses are outlined in our study protocol [ 10 ] and results will be reported once these data are available.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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Background Hospitalisation rates for older people are increasing, with end-of-life care becoming a more medicalised experience. Innovative approaches are warranted to support early identification of the end-of-life phase, communicate prognosis, provide care consistent with people’s preferences, and improve the use of healthcare resources. The Intervention for Appropriate Care and Treatment (InterACT) trial aimed to increase appropriate care and treatment decisions for older people at the end of life, through implementation of a prospective feedback loop. This paper reports on the care review outcomes. Methods A stepped-wedge randomised controlled trial was conducted in three large acute hospitals in Queensland, Australia between May 2020 and June 2021. The trial identified older people nearing the end of life using two validated tools for detecting deterioration and short-term death. Admitting clinical teams were provided with details of patients identified as at-risk with the goal of increasing awareness that end of life was approaching to facilitate appropriate patient centred care and avoid non-beneficial treatment. We examined the time between when the patient was identified as ‘at-risk’ and three outcomes: clinician-led care review discussions, review of care directive measures and palliative care referrals. These were considered useful indicators of appropriate care at the end of life. Results In two hospitals there was a reduction in the review of care directive measures during the intervention compared with usual care at 21 days (reduced probability of − 0.08; 95% CI: − 0.12 to − 0.04 and − 0.14; 95% CI: − 0.21 to − 0.06). In one hospital there was a large reduction in clinician-led care review discussions at 21 days during the intervention (reduced probability of − 0.20; 95% CI: − 0.28 to − 0.13). There was little change in palliative care referrals in any hospital, with average probability differences at 21 days of − 0.01, 0.02 and 0.04. Discussion The results are disappointing as an intervention designed to improve care of hospitalised older people appeared to have the opposite effect on care review outcomes. The reasons for this may be a combination of the intervention design and health system challenges due to the pandemic that highlight the complexity of providing more appropriate care at the end of life. Trial registration Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).

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A stepped-wedge randomised-controlled trial assessing the implementation, impact and costs of a prospective feedback loop to promote appropriate care and treatment for older patients in acute hospitals at the end of life: study protocol

Cited by 4 publications

References 42 publications

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

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

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

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

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