Joan G Carpenter1,2,3, Winifred Josephine Scott4, Jennifer Kononowech5, Mary Beth Foglia6,7, Leah M Haverhals8,9, Robert Hogikyan10,11, Ann Kolanowski12, Zach Landis-Lewis13, Cari Levy8,9, Susan C Miller14, V J Periyakoil4,15, Ciaran S Phibbs4,15, Lucinda Potter6, Anne Sales5,16, Mary Ersek2,3,17. 1. Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, Maryland, USA. 2. Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA. 3. Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA. 4. Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, California, USA. 5. Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA. 6. Veterans Health Administration, National Center for Ethics in Health Care, Washington, District of Columbia, USA. 7. School of Medicine, Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA. 8. Denver-Seattle Center of Innovation, Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System, Aurora, Colorado, USA. 9. Division of Health Care Policy and Research, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA. 10. Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA. 11. GRECC, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA. 12. Penn State, Ross & Carol Nese College of Nursing, University Park, Pennsylvania, USA. 13. University of Michigan Medical School, Ann Arbor, Michigan, USA. 14. Brown University School of Public Health, Warwick, Rhode Island, USA. 15. Stanford University School of Medicine, Stanford, California, USA. 16. Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA. 17. Leonard Davis Institute, Philadelphia, Pennsylvania, USA.
Abstract
OBJECTIVE: To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented. DATA SOURCES: Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020. STUDY DESIGN: In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites. DATA COLLECTION METHODS: Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation. PRINCIPAL FINDINGS: LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72). CONCLUSIONS: Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support.
OBJECTIVE: To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented. DATA SOURCES: Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020. STUDY DESIGN: In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites. DATA COLLECTION METHODS: Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation. PRINCIPAL FINDINGS: LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72). CONCLUSIONS: Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support.
Keywords:
United States Department of Veterans Affairs; Veteran; advance care planning; implementation science; interrupted time series analysis; nursing homes
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