Main results. A total of 360 facilities were included in the study, 119 intervention and 241 control facilities. For the primary outcome, 4171 residents with advanced illness were included in the intervention group and 8308 residents with advanced illness were included in the control group. The average age was 83.6 years in both groups. In the intervention and control groups, respectively, 71.2% and 70.5% were female, 78.4% and 81.5% were White, 68.6% and 70.1% had advanced dementia at baseline, and 35.4% and 33.4% had advanced congestive heart failure or chronic obstructive pulmonary disease at baseline. Approximately 34% of residents received hospice care at baseline. In the intervention and control groups, 43.9% and 45.3% of residents died during follow-up, and the average length of follow-up in each group was 253.1 days and 252.6 days, respectively.
For the primary outcome of hospital transfers per 1000 person-days alive, there were 3.7 episodes (standard error 0.2) in the intervention group and 3.9 episodes in the control group (standard error 0.3); the difference was not statistically significant. For residents without advanced illness, there also was no difference in the hospital transfer rate. For other secondary outcomes, the proportion of residents in the intervention and control groups with 1 or more hospital transfer was 40.9% and 41.6%, respectively; the proportion with 1 or more burdensome treatment was 9.6% and 10.7%; and hospice enrollment was 24.9% and 25.5%. None of these differences was statistically significant. In the intervention group, 55.6% of residents or proxies were offered the video intervention and 21.9% were shown the videos at least once. There was substantial variability in the proportion of residents in the intervention group who were shown videos.
Conclusion. The advance planning video program did not lead to a reduction in hospital transfer, burdensome treatment, or changes in hospice enrollment. Acceptance of the intervention by residents was variable, and this may have contributed to the null finding.
Commentary
Nursing home residents often have advanced illness and limited functional ability. Hospital transfers may be burdensome and of limited clinical benefit for these patients, particularly for those with advanced illness and limited life expectancy, and are associated with markers of poor quality of end-of-life care, such as increased rates of stage IV decubitus ulcer and feeding-tube use towards the end of life.1 Advance care planning is associated with less aggressive care towards the end of life for persons with advanced illness,2 which ultimately improves the quality of end-of-life care for these individuals. Prior interventions to improve advance care planning have had variable effects, while video-based interventions to improve advance care planning have shown promise.3
This pragmatic randomized trial assessed the effect of an advance care planning video program on important clinical outcomes for nursing home residents, particularly those with advanced illness. The results, however, are disappointing, as the video intervention failed to improve hospital transfer rate and burdensome treatment in this population. The negative results could be attributed to the limited adoption of the video intervention in the study, as only 21.9% of residents in the intervention group were actually exposed to the intervention. What is not reported, and is difficult to assess, is whether the video intervention led to advance care planning, as would be demonstrated by advance directive documentation and acceptance of goals of care of comfort. A per-protocol analysis may be considered to demonstrate if there is an effect on residents who were exposed to the intervention. Nonetheless, the low adoption rate of the intervention may prompt further investigation of factors limiting adoption and perhaps lead to a redesigned trial aimed at enhancing adoption, with consideration of use of implementation trial designs.