Increasing goals of care conversations in primary care: Study protocol for a cluster randomized, pragmatic, sequential multiple assignment randomized trial.

Autor: Bekelman DB; VA Eastern Colorado Health Care System, Aurora, CO, USA; University of Colorado Anschutz Medical Campus, Aurora, CO, USA. Electronic address: david.bekelman@va.gov., Giannitrapani K; Center for Innovation to Implementation VA Palo Alto Healthcare System, USA; Stanford University School of Medicine, Primary Care and Population Health, Palo Alto, CA, USA., Linn KA; Division of Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA., Langner P; VA Eastern Colorado Health Care System, Aurora, CO, USA., Sudore RL; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA., Rabin B; VA Eastern Colorado Health Care System, Aurora, CO, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA; UC San Diego ACTRI Dissemination and Implementation Science Center, University of California San Diego, La Jolla, CA, USA., Lorenz KA; Center for Innovation to Implementation VA Palo Alto Healthcare System, USA; Stanford University School of Medicine, Primary Care and Population Health, Palo Alto, CA, USA., Foglia M; VA National Center for Ethics in Health Care, USA; Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA., Glickman A; University of Colorado Anschutz Medical Campus, Aurora, CO, USA., Pawlikowski S; Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA., Sloan M; VA Eastern Colorado Health Care System, Aurora, CO, USA., Gamboa RC; Center for Innovation to Implementation VA Palo Alto Healthcare System, USA., McCaa MD; Center for Innovation to Implementation VA Palo Alto Healthcare System, USA., Hines A; VA Eastern Colorado Health Care System, Aurora, CO, USA., Walling AM; University of California, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
Jazyk: angličtina
Zdroj: Contemporary clinical trials [Contemp Clin Trials] 2024 Oct; Vol. 145, pp. 107643. Date of Electronic Publication: 2024 Jul 27.
DOI: 10.1016/j.cct.2024.107643
Abstrakt: Background: Goals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations.
Methods: We plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders.
Conclusion: This study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.
Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
(Published by Elsevier Inc.)
Databáze: MEDLINE
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