针对终末期老年患者提供适当护理和治疗的定制式助推干预措施的效果评估。
Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life.
机构信息
Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.
Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia.
出版信息
BMC Geriatr. 2024 Feb 28;24(1):202. doi: 10.1186/s12877-024-04818-4.
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).
背景
非有益治疗会影响相当一部分住院老年人，一些老年人在生命末期会选择拒绝侵入性治疗。干预以实现适当的关怀和治疗（InterACT）试验是一项为期 12 个月的逐步楔形随机对照试验，在澳大利亚布里斯班的三家医院进行了嵌入式过程评估。目的是通过实施前瞻性反馈循环的推动干预来增加老年人临终关怀和治疗的决策。然而，试验结果表明，预期的实践改变并未发生。该过程评估旨在使用实施综合框架评估实施情况，确定实施的障碍和促进因素，并深入了解 InterACT 干预措施缺乏效果的原因。
方法
定性数据收集涉及 38 名参与临床医生、监督干预的执行顾问小组在现场层面的成员、临床审核员和项目负责人的半结构化访谈。在线访谈分两个时间点进行：实施开始和完成。数据按照实施综合框架进行编码并进行演绎分析。
结果
总体而言，临床医生认为 InterACT 的前提和临床推理是强有力的，可以改善患者管理。然而，几个突出的障碍影响了实施。这些障碍与推动干预的效力及其整合到常规临床实践、临床医生的信念和感知的自我效能，以及卫生系统层面的更广泛的背景因素有关。
结论
旨在改变接近生命末期患者临床实践的干预措施没有达到预期效果。未来针对这一护理领域的干预措施应考虑使用多组件策略，以解决确定的实施障碍和临床医生实践改变。
试验注册
澳大利亚新西兰临床试验注册中心（ANZCTR），ACTRN12619000675123p（2019 年 5 月 6 日批准）。
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