Ann L Jennerich1, Lois Downey2, Ruth A Engelberg2, J Randall Curtis2. 1. Department of Medicine (A.L.J., L.D., R.A.E., J.R.C.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (A.L.J., L.D., R.A.E., J.R.C.), University of Washington, Seattle, Washington, USA. Electronic address: along11@uw.edu. 2. Department of Medicine (A.L.J., L.D., R.A.E., J.R.C.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (A.L.J., L.D., R.A.E., J.R.C.), University of Washington, Seattle, Washington, USA.
Abstract
CONTEXT: Interventions to promote serious illness conversations have shown promise in promoting high-quality care. However, in randomized trials, some participants may benefit more from the intervention than others. OBJECTIVES: To examine heterogeneity of treatment effect and identify subgroups of patients with serious illness who might benefit most from interventions to enhance communication about goals of care. METHODS: We used data from a multi-center cluster-randomized trial evaluating a communication intervention to increase goals-of-care discussions in the outpatient setting. Patients (n = 249 intervention, n = 288 usual care) had serious illness with an expected median survival of two years. Using model-based recursive partitioning, we tested heterogeneity of the intervention's effect on the occurrence of patient-reported goals-of-care discussions, electronic health record documentation of goals-of-care discussions, patients' ratings of quality of communication, and patients' symptoms of psychological distress at three and six months. RESULTS: We found two significant interactions. For patients' overall rating of clinician communication (n = 251), the intervention effect was positive for patients with higher household income, but not those with lower income (P < 0.001). For patients' symptoms of depression at six months (n = 288), the intervention was associated with fewer symptoms of depression among those whose self-assessed health was poor, but not among those with fair to excellent health (P < 0.001). CONCLUSIONS: Identifying heterogeneity of treatment effect can be a valuable exercise following completion of a randomized trial. Interactions between the intervention and patient income and self-assessed health suggest these factors could be used to design more effective interventions to enhance communication about goals of care.
CONTEXT: Interventions to promote serious illness conversations have shown promise in promoting high-quality care. However, in randomized trials, some participants may benefit more from the intervention than others. OBJECTIVES: To examine heterogeneity of treatment effect and identify subgroups of patients with serious illness who might benefit most from interventions to enhance communication about goals of care. METHODS: We used data from a multi-center cluster-randomized trial evaluating a communication intervention to increase goals-of-care discussions in the outpatient setting. Patients (n = 249 intervention, n = 288 usual care) had serious illness with an expected median survival of two years. Using model-based recursive partitioning, we tested heterogeneity of the intervention's effect on the occurrence of patient-reported goals-of-care discussions, electronic health record documentation of goals-of-care discussions, patients' ratings of quality of communication, and patients' symptoms of psychological distress at three and six months. RESULTS: We found two significant interactions. For patients' overall rating of clinician communication (n = 251), the intervention effect was positive for patients with higher household income, but not those with lower income (P < 0.001). For patients' symptoms of depression at six months (n = 288), the intervention was associated with fewer symptoms of depression among those whose self-assessed health was poor, but not among those with fair to excellent health (P < 0.001). CONCLUSIONS: Identifying heterogeneity of treatment effect can be a valuable exercise following completion of a randomized trial. Interactions between the intervention and patient income and self-assessed health suggest these factors could be used to design more effective interventions to enhance communication about goals of care.
Authors: Laura C Hanson; Sheryl Zimmerman; Mi-Kyung Song; Feng-Chang Lin; Cherie Rosemond; Timothy S Carey; Susan L Mitchell Journal: JAMA Intern Med Date: 2017-01-01 Impact factor: 21.873
Authors: J Randall Curtis; Lois Downey; Anthony L Back; Elizabeth L Nielsen; Sudiptho Paul; Alexandria Z Lahdya; Patsy D Treece; Priscilla Armstrong; Ronald Peck; Ruth A Engelberg Journal: JAMA Intern Med Date: 2018-07-01 Impact factor: 21.873
Authors: Kurt Kroenke; Tara W Strine; Robert L Spitzer; Janet B W Williams; Joyce T Berry; Ali H Mokdad Journal: J Affect Disord Date: 2008-08-27 Impact factor: 4.839