acp crio study design & early results - covenant health · 2015-12-23 · health care provider...
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ACP CRIOStudy Design & Early Results
Dr Konrad Fassbender for Dr Jessica Simon, Dr Neil Hagen and the ACP CRIO Collaborative membership
25th Annual PalliativeResearch and Education Days
October 28, 2014
Disclosure
This program of research has received financial support from AIHS.
This program has received in-kind support from AHS, Covenant Health, UofA and UofC.
Relationships with commercial interests:
— Grants/Research Support: None
— Speakers Bureau/Honoraria: None
— Consulting Fees: None
— Other: Employee UofA, Salary Covenant Health
What’s in a name? ACP CRIO
Advance Care Planning and Goals of Care Alberta:
a Population Based Knowledge Translation
Intervention Study
Collaborative Membership:
Dr. Sara Davison
Dr. Sunita Ghosh
Dr. Jayna Holroyd-Leduc
Karen Macmillan
Gordon Self
Dr. Eric Wasylenko
Dr. Robin Fainsinger
Dr. Daren Heyland
Dr. Jonathan Howlett
Nola Ries
Dr. Ann Syme
Tracy Lynn Wityk-Martin
Trainees:Dr. Shannon CunninghamDr. Petra GrendarovaMaryam NesariMarta Shaw
Support Staff:Dr. Patricia BiondoMaureen DouglasLauren Ogilvie
Dr. Neil Hagen
Dr. Jessica Simon
Dr. Konrad Fassbender
Co-Leads:
ACP CRIO Team
KT network
Hot off the press…
Congratulations to Patricia Biondo and Maureen Douglas
The Campus Alberta Health Outcomes and Public Health committee would like to congratulate you for submission of a successful application for funding to support a pan-Alberta gathering of stakeholders in Health Outcomes and Public Health.
Communicating decisions around life sustaining
therapy and end of life care in Alberta
Advance care planning
- Communication process
Personal Directive
- Legal document, names agent
Goals of Care designations
- Medical Order
The Elements of ACP
• Think about your values and wishes
• Learn about your own health
• Choose someone to make decisions and
speak on your behalf
• Communicate your wishes and values about
health care
• Document in a Personal Directive
Goals of Care Designations
A Goal of Care Designation
provides direction regarding:
General intent of care,
Specific health interventions,
Locations of care,
Transfer decisions.
Elements of GCD discussions
• Prognosis “What does this mean for me?”
• Explore patient’s values, understanding, hopes
and fears
• Role & anticipated outcomes of treatments
(comfort, medical, resuscitative)
• Available resources (palliative care, SW, Spiritual)
• Documentation (tracking record, GCD form)
Many Unanswered Questions
1. What are the barriers & facilitators to ACP uptake and readiness to change in Alberta for different stakeholder groups? Will these change with provincial implementation?
2. Are ACP tools effective to engage users, increase knowledge and change behavior? What tailored improvements or methods of implementing tools will change their effectiveness?
3. What are the most informative measures to monitor practice change and communicate results to end-users?
4. What is the impact of ACP/GCD on the trajectory of care and costs for dying patients?
Advance Care Planning and Goals of Care Alberta: a
population based Knowledge Translation intervention study
Knowledge to action cycle
ACP National Framework
From Advance Care Planning in Cabada : National Framework 2012
http://www.advancecareplanning.ca/media/40158/acp%20framework%202012%20eng.pdf
Engagement Education
System Infrastructure
Continuous Quality Improvement
Provincial Policy for ACP GCD
The framework in Alberta
Study contexts
Seniors (supportive living facilities)
Cancer (out-patient clinics)
Chronic Disease (renal and heart failure)
Primary Care
Marginalized Populations (cultural, religious)
What?
Research activities
1. Assess barriers & facilitators and readiness to participate in ACP/GCD from public and HCP perspectives
2. Assess tools for education and engagement & evaluate how best to adapt to local environment
3. Assess indicators to monitor uptake of ACP/GCD & to guide continuous QI
4. Determine the economic consequences of ACP/GCD implementation
Methods
Activity 1: Qualitative, public polls, surveys (patients, HCP, SCN, legal profession)
Activity 2: Qualitative, RCT of video tool, Low & high facilitation interventions, Website usage
Activity 3: Delphi process to develop performance indicators, Dashboard development, Monitor dashboard usage
Activity 4: Retrospective databases CZ vs AB, Prospective analysis of the RCT cohort, Budget impact modeling
How?
1.1 Qualitative studies
• Patients (cancer, RF, HF, SL)
• HCP (MD, RN, allied, administrator)
• Public (3 language/sociocultural groups)
• Collaborative qualitative researcher
group
1 2 3 4 5Year:
Assess Barriers & Facilitators
1.2 Public Polls
1 2 3 4 5Year:
Assess Barriers & Facilitators
1.3 Partnering studies
a) DECIDE (yr 2)
b) SCN survey (seniors, cancer,
cardiovasc & stroke) (yr 1)
c) Lawyers - legal tool kit year (yr 3)
d) ACCEPT - (yr 3 & 5)
1 2 3 4 5Year:
Assess Barriers & Facilitators
2.1 Qualitative feedback on existing tools
a) Via activity 1.1
b) Direct observation of tools in use in
the out-pt clinic context (critical
ethnography)
1 2 3 4 5Year:
Evaluate Tools
2.2 RCT of video effectiveness
• Video vs oral narrative of ACP & GCD
• HF & RF clinic patients
• Piggy back health economic evaluation
1 2 3 4 5Year:
Evaluate Tools
2.3 Observational study of low vs high facilitation
Compare units providing access to resources vs intentional, facilitated initiatives to improve quality/quantity of ACP GCD
1 2 3 4 5Year:
Evaluate Tools
2.4 Use of AHS website
Monitor website use + potential for user
evaluation survey
www.albertahealthservices.ca/advancecareplanning.asp
1 2 3 4 5Year:
Evaluate Tools
3.1 Develop performance indicators
Build on current Delphi process:
Context specific indicators
Patient-related, HCP & admin outcomes
1 2 3 4 5Year:
Monitor uptake
3.2 ACP Alberta dashboard
Create in partnership with AHS IT
Provide benchmark data to HCP and
administrators across the province
1 2 3 4 5Year:
Monitor uptake
3.3 Use of dashboard
Use by HCP & administrators
Aim is to identify the smallest number of
reliable key indicators
1 2 3 4 5Year:
Monitor uptake
4.1 Analysis of existing databases
Calgary vs rest of Alberta for 2004-2012
(i.e. pre & post policy implementation in
Calgary 2008)
1 2 3 4 5Year:
Evaluate outcomes
4.2 Prospective economic analysis with cohort from 2.2
Use Health Services Inventory for the
cohort enrolled in the GCD video study
1 2 3 4 5Year:
Evaluate outcomes
4.3 Modeling future impact of ACP/GCD
Budget impact analysis & policy
implications
Hypothesis: Cost shifting
1 2 3 4 5Year:
Evaluate outcomes
Summary
• Alberta: leading with provincial policy implementation across complex healthcare system
• Resources available
• Opportunity to study the outcomes of the implementation, guide healthcare decision makers and enable KT
• ACCEPT and CRIO both inviting new investigators and collaborators
Early results
Activity 1.1
Activity 1.1 is a qualitative investigation of the attitudes, barriers, facilitators, and readiness of patients, family members, and clinicians to participate in Advance Care Planning. The investigation is taking place with several populations of interest: Cardiac and Cancer (Edmonton), and Renal and Supportive Living (Calgary)
Recruiting to participate in a 1-hour semi-structured interview
Recruitment has been underway since the summer of 2014 and is expected to wrap up by Christmas; active coding and qualitative analysis of transcripts has been going on throughout the recruitment process
Activity 1.1 Recruitment
Clinicians Patients / Residents
Family Members
Total
Cancer 7 3 2 12
Cardiac 4 2 0 6
Renal 2 9 6 17
Supportive Living
8 9 7 24
Total 21 23 15 59
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
HeardofACP? RecognizeACPdefini on?
Discussedwithfamily/friends?
DiscussedwithHCP? Havewri enACP? Haveawri enPersonalDirec ve?
Percentage"Yes"(%)
ACPElement
HQCA2007
ACPCRIO2013
Public polls - increasing ACP engagement Alberta 2007 vs 2013
Domains of behaviour change in use of guidelines within health care (Michie et al)
Domains Construct (abbreviated)
Knowledge Knowledge, Scientific Rationale, Procedural Knowledge
Skills Skills, Competence, Skill Assessment
Social/Prof. Role/Identity Identity, Professional Identity, Roles, Boundaries
Beliefs about Capabilities Self-Efficacy, Empowerment, Self-Esteem, Control
Beliefs about Consequences Outcome expectations, Regret, Attitudes, Reward/Sanctions
Motivation and Goals Intention, Goals, Priorities, Commitment
Memory & Decision Process Memory, Attention Control, Decision Making
Environmental Context Resources (Material or Other)
Social Influences Social Support, Group Norms, Conformity, Leadership
Emotion Affect, Stress, Regret, Fear, Threat
Behavioral Regulation Goals, Implementation Intention, Self Monitoring
Nature of the Behavior Routine, Automatic Habit or Breaking a Habit,
Optimism Hope for Improvement/Change
Reinforcement Behavioral Reinforcement (intended and unintended)
DOMAIN ELEMENT n=51 %
Public/patient factors
Insufficient public engagement Public misunderstanding
4341
8480
Systems factors
Conflict because of too many other AHS initiativesLack of infrastructure, especially expert staff Ineffective public awareness campaign
424037
827873
ResourcesAdequate time for ACP/GCD conversations Need for electronic record capability to track GCD orders and ACP conversations
40
35
78
69
Health care provider factors
Health Care Provider’s mastery of GCD Ineffective staff education program Emotional discomfort initiating ACP / GCD conversations
312625
615149
Strategic Clinical Networks Survey
Major barriers were identified across three SCNs: Cancer, Seniors, and Cardiovascular and stroke
Drs. Hagen, Howlett, Holroyd Leduc, Sharma
Key enablers to mitigate these barriers
DOMAIN ELEMENT
Public/patient factors
Develop an impactful public awareness campaign so that patients and families are better prepared to participate in discussions
Systems factors Leadership to communicate the high priority of ACP/GCDfor frontline staff
Resources Develop an electronic record to track ACP and GCDconversations
Health care provider factors
Provide HCP with training on conversation scripts and simple messages on ACP/GCD to promote comfort with the conversations
Identified facilitators via focused discussion with CC SCN
HCP survey and Behaviour Change Wheel
Slide from Dr Jayna Holroyd-Leduc
Summary of evaluation outcomes by healthcare setting (n=37)
Indicator Community Primary
care
Out-pt
clinics
Acute
care
Continuing
care
Multiple
settings
Total
# of studies reporting the indicator (n)
Patients’ EOL treatment preferences are documented 1 2 3 3 17 5 31
Evidence that ACP discussions have occurred 1 1 2 3 14 3 23
Healthcare resource utilization (e.g. CPR use, hospital
admissions)
0 0 2 0 9 5 16
System processes and infrastructure are in place to
support ACP
0 1 2 2 5 5 15
A medical order is present in the patient’s chart 0 0 0 1 7 6 14
Concordance measures/compliance with EOL treatment
preferences
1 0 0 2 5 4 12
Patient-reported outcomes (e.g. QOL, satisfaction, quality
of care)
0 1 2 1 2 1 7
HCP-reported outcomes (e.g. satisfaction, confidence,
knowledge)
0 0 1 2 1 0 4
Family/caregiver-reported outcomes (e.g. distress, QOL,
satisfaction)
0 0 0 1 1 0 2
Palliative care indicators (e.g. EOL register, EOL care
pathway)
0 0 0 0 1 1 2
Economic outcomes 0 0 0 0 1 0 1
Additional Partnering Studies
GCD in Calgary Zone – 5 years of acute care data
iDECIDE – acute care interventional studies
D2C – patient feedback tool for resident education
Talk to me - seriously ill patients’ views on physician behaviours that influence the quality of end-of-life communication
Thank-you!
http://www.acpcrio.org/