Volandes Angelo E, Chang Yuchiao, Lakin Joshua R, Paasche-Orlow Michael K, Lindvall Charlotta, Zupanc Seth N, Martins-Welch Diana, Carney Maria T, Burns Edith A, Itty Jennifer, Emmert-Tangredi Kaitlin, Martin Narda J, Sanghani Shreya, Tilburt Jon, Pollak Kathryn I, Davis Aretha Delight, Garde Cynthia, Barry Michael J, El-Jawahri Areej, Quintiliani Lisa, Sciacca Kate, Goldman Julie, Tulsky James A
Department of Medicine, Dartmouth Health, Lebanon, New Hampshire.
Geisel School of Medicine, Hanover, New Hampshire.
JAMA Netw Open. 2025 May 1;8(5):e259150. doi: 10.1001/jamanetworkopen.2025.9150.
Many older adults with advanced cancer never communicate goals of care or treatment preferences to their clinicians, raising the risk that care received will not match their values. Scalable models of care may help surmount this barrier.
To test whether a combined patient and clinician intervention increased the rate of advance care planning (ACP) documentation in large health care systems.
DESIGN, SETTING, AND PARTICIPANTS: This stepped-wedge cluster randomized clinical trial using an open cohort design included patients aged 65 years or older with advanced cancer seen at oncology clinics in 3 health care systems located in the US South, Midwest, and Mid-Atlantic regions from April 1, 2020, to November 30, 2022. Data collection ended in 2024.
The intervention involved delivering brief evidence-based patient-facing video decision aids available in 25 languages as well as goals-of-care communication training to oncology clinicians. Patients in the control period received usual care.
The primary outcome was ACP documentation, which included any electronic health record documentation of a goals-of-care conversation, palliative care, hospice, or limitation of life-sustaining treatments, identified via a validated natural language processing program. Analysis was performed on an intention-to-treat basis.
Twenty-nine practices, comprising 13 800 unique eligible patients with a total of 29 357 repeated measurements, were included (mean [SD] age, 74.5 [6.6] years; 52.3% men [15 344 of 29 357 measurements]). The proportion of patients with ACP documentation was greater in the intervention phase compared with the usual care phase (adjusted rate difference, 6.8% [95% CI, 2.8%-10.8%]; P < .001). ACP documentation in the intervention phase occurred among 3980 of 15 754 patients (25.3%) (goals-of-care conversation, 21.4% [3377 of 15 754]; palliative care, 9.6% [1517 of 15 754]; hospice, 5.4% [847 of 15 754]; and limitation of life-sustaining treatments, 7.2% [1128 of 15 754]). In comparison, ACP documentation in the usual care phase occurred among 2834 of 13 603 patients (20.8%) (goals-of-care conversation, 16.8% [2281 of 13 603]; palliative care, 9.5% [1287 of 13 603]; hospice, 5.3% [724 of 13 603]; and limitation of life-sustaining treatments, 8.4% [1149 of 13 603]).
In this stepped-wedge cluster randomized clinical trial for older adults with advanced cancer, a bundled evidence-based decision aid and communication training intervention increased the proportion of older patients with ACP documentation. This approach offers an innovative paradigm with a clinically meaningful increase in ACP documentation, a widely used quality metric that reflects high-quality patient-centered care delivery.
ClinicalTrials.gov Identifier: NCT03609177.
许多患有晚期癌症的老年人从未向其临床医生传达护理目标或治疗偏好，这增加了所接受的护理与他们的价值观不符的风险。可扩展的护理模式可能有助于克服这一障碍。
测试患者和临床医生联合干预是否能提高大型医疗系统中预先护理计划（ACP）文件记录的比例。
设计、设置和参与者：这项采用开放队列设计的阶梯式楔形整群随机临床试验纳入了2020年4月1日至2022年11月30日期间在美国南部、中西部和大西洋中部地区的3个医疗系统的肿瘤诊所就诊的65岁及以上患有晚期癌症的患者。数据收集于2024年结束。
干预措施包括为肿瘤临床医生提供25种语言的简短循证患者导向视频决策辅助工具以及护理目标沟通培训。对照组患者接受常规护理。
主要结局是ACP文件记录，包括通过经过验证的自然语言处理程序识别的任何关于护理目标对话、姑息治疗、临终关怀或维持生命治疗限制的电子健康记录文件。分析采用意向性分析。
纳入了29个医疗实践机构，包括13800名独特的符合条件的患者，共进行了29357次重复测量（平均[标准差]年龄，74.5[6.6]岁；52.3%为男性[29357次测量中的15344次]）。与常规护理阶段相比，干预阶段有ACP文件记录的患者比例更高（调整后的率差为6.8%[95%置信区间，2.8%-10.8%]；P<.001）。干预阶段，15754名患者中有3980名（25.3%）有ACP文件记录（护理目标对话，21.4%[15754名中的3377名]；姑息治疗，9.6%[15754名中的1517名]；临终关怀，5.4%[15754名中的847名]；维持生命治疗限制，7.2%[15754名中的1128名]）。相比之下，常规护理阶段，13603名患者中有2834名（20.8%）有ACP文件记录（护理目标对话，16.8%[13603名中的2281名]；姑息治疗，9.5%[13603名中的1287名]；临终关怀，5.3%[13603名中的724名]；维持生命治疗限制，8.4%[13603名中的1149名]）。
在这项针对患有晚期癌症的老年人的阶梯式楔形整群随机临床试验中，一项综合的循证决策辅助工具和沟通培训干预提高了有ACP文件记录的老年患者比例。这种方法提供了一种创新模式，使ACP文件记录有了具有临床意义的增加，ACP文件记录是一个广泛使用的质量指标，反映了以患者为中心的高质量护理提供情况。
ClinicalTrials.gov标识符：NCT03609177。
