An advanced care planning (ACP) video initiative failed to reduce hospital transfers, decrease advanced treatments, or increase the use of hospice among US nursing home residents, according to a study published in JAMA Internal Medicine.1
The study authors designed the Pragmatic Trial of Video Education in Nursing Homes (PROVEN) initiative to improve communication between staff, residents, and caregivers about end-of-life issues. Residents of 360 nursing homes were randomized to receive either the video intervention (n=119) or standard of care (n=241). Long-stay (>100 days) residents with advanced illness (dementia or cardiopulmonary disease) were identified as the subgroup with the greatest opportunity and need to improve ACP.
While the control nursing homes continued their standard ACP procedures, staff at the 119 nursing homes that implemented PROVEN underwent a 1-month training period and employed 2 ACP video program social workers, referred to as “champions,” who were tasked with showing videos to patients and their families. Each nursing home system also employed a senior project manager to supervise the initiative’s implementation.
The video ACP program consisted of 5 short videos in English or Spanish — titled General Goals of Care, Goals of Care for Advanced Dementia, Hospice, Hospitalization, and ACP for Healthy Patients.Champions offered videos to all residents and their proxies at the following times: within 7 days of readmission; every 6 months; when specific decisions arose; and under special circumstances (ie, family visit).
Champions were responsible for selecting which video(s) to offer; they were instructed to complete a report into a patient’s electronic medical record whenever they were offered a video, and indicated whether the patient viewed or refused the video. Champions met regularly with the research team to collaborate on solutions for addressing nonadherance and motivating engagement.
Prevalence of advanced illness was similar between the intervention and control groups. At baseline, 1426 of 4171 residents in the intervention group (34.2%) were receiving hospice care compared with 2875 of 8308 residents in the control group (34.6%). Over the 1-year follow-up period, 1829 (43.9%) of residents in the intervention group died compared with 3764 (45.3%) in the control group.
Approximately 55.6% of the intervention group residents with advanced illness, or their proxies, were offered the chance to watch a video; 21.9% were shown a video at least once. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities) to >40% (22 facilities).
The rate of hospital transfers per 1000 person-days alive was not statistically reduced in the intervention group compared with the control group (3.7 vs 3.9; respectively) nor was the percentage of patients who had a least 1 hospital transfer (41.1% vs 41.4%, respectively. In addition, the proportion of resident experiencing any burdensome treatment and who enrolled in hospice did not significantly differ between the study groups.
“As one of the first large, pragmatic randomized clinical trials to be conducted in the nursing home setting, PROVEN’s inability to demonstrate a significant effect on hospital transfer rates and other outcomes among long-stay residents is sobering,” researchers concluded.
Mitchell LS, Volandes AE, Gutman R, et al. Advanced care planning video intervention among long-stay nursing home residents a pragmatic cluster randomized trial. JAMA Intern Med. 2020;180(8):1070-1078.