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

Abstract

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).

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

“…Within the trial, these three indicators -clinician led review, review of care directive measures, palliative care referrals -were measured as indicators of appropriate care at end-of-life. The published ndings of these indicators show that the InterACT intervention did not achieve the intended goal of prompting clinicians as intended (20). This process evaluation paper aims to provide an explanation for the observed ndings that InterACT did not change clinical practice to improve appropriate care at end-of-life.…”

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

“…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.…”

“…Within the trial, these three indicators – clinician led review, review of care directive measures, palliative care referrals – were measured as indicators of appropriate care at end-of-life. The published findings of these indicators show that the InterACT intervention did not achieve the intended goal of prompting clinicians as intended [ 20 ]. This process evaluation paper aims to provide an explanation for the observed findings that InterACT did not change clinical practice to improve appropriate care at end-of-life.…”

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

“…This paper reports the trial’s primary outcome and secondary outcomes 2, 3 and 7. We have previously reported on secondary outcomes 4, 5 and 6 using data immediately available on trial completion [ 16 ]. The cost-consequence analysis, outcomes 8 and 9, will be published separately, and the process evaluation results (outcome 10) are available [ 17 ].…”

“…The results from outcomes 4, 5 and 6 were disappointing as an intervention designed to improve care of hospitalised older people appeared to have the opposite effect on care review outcomes [ 16 ]. The reasons for this may be a combination of the intervention design, further discussed in the process evaluation [ 17 ], and health system challenges due to the COVID-19 pandemic.…”