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期刊来源：JAMA

文献发表时间：2023-05-21

原文链接：https://jamanetwork.com/journals/jama/article-abstract/2805346

关键点内容如下：

问题

针对患者的、面向临床医生的沟通启动干预（快速启动指南）与讨论提示能否有效促进临床医生与患有严重疾病的住院老年患者之间的护理目标讨论？

调查结果

在这项包含2512名住院患者的实用随机临床试验中，面向临床医生的干预导致30天内记录护理目标讨论的患者比例显著增加（干预组34.5%的患者与常规护理组30.4%的患者相比）。在种族或少数民族患者中，干预的效果更大。

意义

这些研究结果表明，面向临床医生的提示干预措施促进了护理目标的讨论，特别是在种族或少数民族患者中。

摘要内容如下：

重要性

关于护理目标的讨论对于高质量的姑息治疗非常重要，但对于患有严重疾病的住院老年患者往往缺乏。

目标

评估沟通启动干预，以促进临床医生和患有严重疾病的住院老年患者之间的护理目标讨论。

研究对象

在1个医疗保健系统内的3家美国医院（包括大学、县和社区医院）进行了一项面向临床医生的沟通启动干预与常规护理的实用随机临床试验。符合条件的住院患者年龄为55岁或以上，患有达特茅斯阿特拉斯项目（Dartmouth Atlas Project）用于研究临终关怀的任何慢性疾病，或年龄为80岁或以上。

排除在入院和资格筛选之间有记录的护理目标讨论或姑息治疗咨询的患者。

随机化发生在2020年4月至2021年3月之间，并根据研究地点和痴呆干预史进行分层对随机接受干预的患者进行治疗的医生和高级实践临床医生接受了一页针对患者的干预（快速启动指南），以促进和指导护理目标讨论。

干涉

治疗随机接受干预的患者的医生和高级实践临床医生接受了一项针对患者的单年龄干预（Jumpstart Guide），以促进和指导护理讨论的目标。

主要结果和措施

主要结果是拥有电子健康记录的患者比例——30天内记录的护理讨论目标。还评估了干预的效果是否因年龄、性别、痴呆症病史、少数民族或民族或研究地点而异。

结果

在3918名接受筛查的患者中，2512名入选（平均年龄71.7[SD，10.8]岁，42%为女性）并随机分组（1255名进入干预组，1257名进入常规护理组）。患者为美洲印第安人或阿拉斯加原住民（1.8%）、亚洲人（12%）、黑人（13%）、西班牙裔（6%），夏威夷原住民或太平洋岛民（0.5%），非西班牙裔（93%）和白人（70%）。在30天内，干预组中有电子健康档案记录的患者比例为34.5%（1255例患者中的433例），而常规护理组为30.4%（1257例患者中的382例）（经医院和痴呆调整的差异为4.1%[95%CI为0.4%-7.8%]）。对治疗效果修正因子的分析表明，在少数族裔或种族的患者中，干预具有较大的效应量。在803名少数民族患者中，干预组经医院和痴呆调整后讨论护理目标的比例比常规护理组高10.2%（95%CI，4.0%-16.5%）。在1641名非西班牙裔白人患者中，与常规护理组相比，干预组调整后的护理目标讨论比例高1.6%（95%CI，-3.0%至6.2%）。

没有证据表明干预对年龄、性别、痴呆病史或研究地点的主要结果有不同的治疗效果。

结论和相关性

在患有严重疾病的住院老年人中，面向临床医生的务实沟通启动干预显著改善了电子健康档案中护理目标讨论的记录，在种族或少数民族患者中具有更大的效应大小。

英文原文如下：

Key Points

Question  Can a patient-specific, clinician-facing communication-priming intervention (Jumpstart Guide) with discussion prompts effectively promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness?

Findings  In this pragmatic, randomized clinical trial of 2512 hospitalized patients, the clinician-facing intervention resulted in a significant increase in the proportion of patients with documented goals-of-care discussions within 30 days (34.5% of patients in the intervention group vs 30.4% in the usual care group). The effect of the intervention was greater among racially or ethnically minoritized patients.

Meaning  These findings suggest that clinician-facing prompting interventions promote goals-of-care discussions, particularly among racially or ethnically minoritized patients.

Abstract

Importance  Discussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness.

Objective  To evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness.

Design, Setting, and Participants  A pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia.

Intervention  Physicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions.

Main Outcomes and Measures  The primary outcome was the proportion of patients with electronic health record–documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site.

Results  Of 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record–documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, −3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site.

Conclusions and Relevance  Among hospitalized older adults with serious illness, 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.