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

Abstract

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) study 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 study at 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 6 May 2019).

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

“…The process evaluation, which included interviews with clinicians enrolled in the trial, revealed that some clinicians felt able to identify patients near the end of life and questioned the sensitivity of the screening tools; specifically, two medical teams from one hospital found that the at-risk score of two for the SPICT tool was achieved by the vast majority of their patients as they all received one point for an unplanned admission [ 17 ]. The interviews also found ‘death denying’ views amongst some clinicians and a perceived lack of educational preparation in end-of-life care.…”

“…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 ]. ICU admission was chosen as the primary outcome due to the increasing number of ICU admissions of older patients [ 18 ] and the potential for highly invasive treatments that unnecessarily increase suffering at the end of life.…”

“…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.…”