As pointed out by the study investigators, other changes to nursing home practices, specifically on hospital transfer, likely occurred during the study period. A number of national initiatives to reduce unnecessary hospital transfer from nursing homes have been introduced, and a reduction in hospital transfers occurred between 2011 and 20174; these initiatives could have impacted staff priorities and adoption of the study intervention relative to other co-occurring initiatives.
Applications for Clinical Practice
The authors of this study reported negative trial results, but their findings highlight important issues in conducting trials in the nursing home setting. Additional demonstration of actual effect on advance care planning discussions and documentation will further enhance our understanding of whether the intervention, as tested, yields changes in practice on advance care planning in nursing homes. The pragmatic clinical trial design used in this study accounts for real-world settings, but may have limited the study’s ability to account for and adjust for differences in staff, settings, and other conditions and factors that may impact adoption of and fidelity to the intervention. Quality improvement approaches, such as INTERACT, have targeted unnecessary hospital transfers and may yield positive results.5 Quality improvement approaches like INTERACT allow for a high degree of adaptation to local procedures and settings, which in clinical trials is difficult to do. However, in a real-world setting, such approaches may be necessary to improve care.
–William W. Hung, MD, MPH