Bailey FA, Williams BR, Goode PS, et al. Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial. J Gen Intern Med. 2021 Feb 5. pii: 10.1007/s11606-020-06482-x. doi: 10.1007/s11606-020-06482-x. (Original study)

BACKGROUND: There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings.

OBJECTIVE: To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs).

DESIGN: Cluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites.

PARTICIPANTS: One hundred thirty-two providers from PCCTs at 47 VAMCs.

INTERVENTIONS: Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers.

MAIN MEASUREMENTS: Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates.

KEY RESULTS: Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement.

CONCLUSION: Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used.

TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02383173.

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Comments from MORE raters

Physician rater

Most clinicians probably already know the quality metrics noted here for good end of life care in actively dying patients. They may not know there was no difference between a F2F and internet implementation. The problem is the numbers are so high that there was little room for improvement in many variables.

Physician rater

This is an interesting cluster randomized controlled trial evaluating in person vs teleconferencing for training of palliative care consultation teams. The authors did not find a difference at a power of 0.86. This is certainly relevant during the COVID-19 pandemic but may improve efficiency if this can be scaled up.

Physician rater

Improving end of life care is everyone's business and this study looked at a training intervention. There was no difference between enhanced training and lighter touch training, but I wonder if this relates to the choice of endpoint. Success was judged by prescription of opiates. I don't think this is a good measure of the quality of end of life care.

Physician rater

Provides insight into how much training is actually needed to implement comfort care orders.

Physician rater

Interesting study. The abstract suggests that the 'method of education' did not affect clinical effectiveness, but I would argue the key finding was that neither method changed any of the clinical parameters measured. While some were high at outset (eg opioid orders) so might not be expected to change, many were much lower than one might want and would therefore hope to see a change. Either way, this is an interesting study.

Physician rater

As an Internist, I find this information may be useful.
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