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. 2022 Aug;57(4):734-743.
doi: 10.1111/1475-6773.13958. Epub 2022 Mar 8.

Evaluating implementation strategies to support documentation of veterans' care preferences

Joan G Carpenter  1   2   3 , Winifred Josephine Scott  4 , Jennifer Kononowech  5 , Mary Beth Foglia  6   7 , Leah M Haverhals  8   9 , Robert Hogikyan  10   11 , Ann Kolanowski  12 , Zach Landis-Lewis  13 , Cari Levy  8   9 , Susan C Miller  14 , V J Periyakoil  4   15 , Ciaran S Phibbs  4   15 , Lucinda Potter  6 , Anne Sales  5   16 , Mary Ersek  2   3   17
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Evaluating implementation strategies to support documentation of veterans' care preferences

Joan G Carpenter et al. Health Serv Res. 2022 Aug.

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.

Keywords: United States Department of Veterans Affairs; Veteran; advance care planning; implementation science; interrupted time series analysis; nursing homes.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

FIGURE 1
FIGURE 1
Project 1 LSTDI template completion rate: intervention CLCs versus comparison CLCs. Δ, comparison CLCs, •, intervention CLCs. Dashed line indicates the start of intervention. LSTDI, Life‐Sustaining Treatment Decisions Initiative
FIGURE 2
FIGURE 2
Project 2 LSTDI template completion rate: intervention CLCs versus comparison CLCs. Δ, comparison CLCs; •, intervention CLCs. Dashed line indicates the start of intervention. LSTDI, Life‐Sustaining Treatment Decisions Initiative
See this image and copyright information in PMC

References

    1. Teno JM, Mitchell SL, Kuo SK, et al. Decision‐making and outcomes of feeding tube insertion: a five‐state study. J Am Geriatr Soc. 2011;59(5):881‐886. - PMC - PubMed
    1. Givens JL, Kiely DK, Carey K, Mitchell SL. Healthcare proxies of nursing home residents with advanced dementia: decisions they confront and their satisfaction with decision‐making. J Am Geriatr Soc. 2009;57(7):1149‐1155. - PMC - PubMed
    1. Kiely DK, Givens JL, Shaffer ML, Teno JM, Mitchell SL. Hospice use and outcomes in nursing home residents with advanced dementia. J Am Geriatr Soc. 2010;58(12):2284‐2291. - PMC - PubMed
    1. Foglia MB, Lowery J, Sharpe VA, Tompkins P, Fox E. A comprehensive approach to eliciting, documenting, and honoring patient wishes for care near the end of life: the Veterans Health Administration's Life‐Sustaining Treatment Decisions Initiative. Jt Comm J Qual Patient Saf. 2019;45(1):47‐56. - PubMed
    1. U.S. Department of Veterans Affairs . About VHA. 2021. Accessed January 22, 2021. https://www.va.gov/health/aboutvha.asp

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