Guide with patient-specific data, talking prompts led to more goals-of-care discussions
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Key takeaways:
- More documentation of conversations about goals-of-care occurred when clinicians had the Jumpstart Guide.
- The effect of the guide/intervention was larger in patients of a racial or ethnic minority.
WASHINGTON — A guide given to clinicians with patient-specific data and talking points resulted in more documented conversations about goals-of-care, according to a presentation at the American Thoracic Society International Conference.
“In hospitalized older adults with serious illness, we found a pragmatic, clinician-facing communication-priming intervention significantly improved documentation of goals of care discussions in the [electronic health record], with a greater effect size in racially or ethnically minoritized patients,” Erin K. Kross, MD, associate professor in the division of pulmonary, critical care and sleep medicine at the University of Washington, said during the presentation.
In a pragmatic, randomized clinical trial, Kross and colleagues analyzed 2,512 hospitalized patients (mean age, 71.7 years; 42% women) across three hospitals who were either aged 80 years or older or aged 55 years or older with a Dartmouth Atlas chronic illness to see if a communication-priming intervention led to more documented goals-of-care clinician-patient discussions in EHRs than usual care within 30 days of randomization.
“The EHR provides opportunities to identify patients who might benefit from goals-of-care discussions, and yet goals-of-care discussions and their documentation remain a shortcoming in many health systems as described by our group and many others,” Kross said.
Of the total cohort, 1,255 patients made up the intervention group, which meant that their clinicians received the Jumpstart Guide via email that included patient-specific EHR data and talking prompts to help them navigate conversations with their patients on their goals of care. The remaining patients received usual care (n = 1,257).
Clinicians also received a reminder message about the Jumpstart Guide via pager, Kross said during her presentation.
Thirty days after randomization, researchers found that more patients whose clinicians received the Jumpstart Guide had EHR-documented goals-of-care discussions compared with patients who received usual care (433 patients vs. 382 patients), and this finding was adjusted for hospital site and history of dementia (adjusted difference, 4.1%; 95% CI, 0.4%-7.8%).
Further, for patients of a race and ethnicity other than non-Hispanic white (n = 803), the Jumpstart Guide intervention was found to have a greater effect, with a 10.2% (95% CI, 4%-16.5%) higher proportion of goals-of-care discussions than usual care following adjustment for hospital site and history of dementia, according to researchers. Goals-of-care discussions in non-Hispanic white patients (n = 1,641) also occurred more when their clinician received the intervention (1.6%; 95% CI, –3% to 6.2%) vs. provided usual care, but this proportion was not as large as that seen in patients of a minoritized race or ethnicity.
According to researchers, age, sex, history of dementia and hospital site did not modify the effect of the intervention.
“We believe that this [study] provides evidence that this low touch intervention can nudge clinicians to change their behaviors,” Kross said. “The prevalence of goals of care discussion in the EHR remains low, suggesting there is still opportunity for improvement.”
Future studies may investigate clinicians’ actions related to the Jumpstart Guide, Kross said.
“We are really interested in focusing on factors related to implementation,” she said. “It’s one thing to deliver this Jumpstart to a clinician via their email, it’s another to understand how they are using it. Are they opening the email? Are they reading it? Are they using the guide? I appreciate that it is a multifaceted, complex problem to get these conversations going.”