Life In The Slower Lane

Here is the structured PICO analysis for the fifty-fifth article you uploaded:

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Full Title (verbatim and exact):

“Effects of an Intervention to Reduce Hospitalizations From Nursing Homes: A Randomized Implementation Trial of the INTERACT Program”

Kane RL, Huckfeldt P, Tappen R, et al.

JAMA Internal Medicine (2017); 177(9):1257–1264

DOI: 10.1001/jamainternmed.2017.2657

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Type of Article:

Cluster-randomised implementation trial (randomised pragmatic trial of a QI intervention)

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PICO Analysis:

Population:

• 85 U.S. nursing homes (NHs) with no prior use of INTERACT tools
• Enrolled from a national pool of 613 screened NHs; included 36,717 long-stay Medicare beneficiaries
• Residents had diverse backgrounds and varying functional and cognitive impairments 

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Intervention:

INTERACT (Interventions to Reduce Acute Care Transfers) program with implementation support:

• Suite of tools including:
  • Early recognition and response to acute change
  • Standardised communication and care paths
  • Advance care planning materials
  • Quality improvement monitoring tools
• Training provided via:
  • Webinars and online modules
  • Monthly phone support
  • Local “champions” and facility implementation leaders 

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Comparator:

• Control NHs (n = 52) received usual care, including either no additional contact or attention control (quarterly QI surveys)
• Control homes were matched for baseline readmission rates and absence of structured INTERACT use 

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Outcome:

1. Person-centred outcomes (indirect):

• No direct resident experience or preference measures
• Advance care planning (ACP) support was a component of INTERACT but not independently measured in this trial

2. Process outcomes:

• Primary outcome:
  • All-cause hospitalisations per 1000 resident-days
    • No significant difference between intervention and control (net difference: –0.13; 95% CI: –0.36 to 0.10; P = .25)
• Secondary outcomes:
  • Potentially avoidable hospitalisations:
    • Small but statistically significant reduction in intervention group (–0.18 per 1000 resident-days; P = .01)
    • However, this was not significant after Bonferroni correction for multiple comparisons
  • No differences in:
    • 30-day readmission rates
    • ED visits without admission
    • Hospitalisations within 30 days of NH admission
    • Hospitalisations after 31 days of NH admission

3. Health system outcomes:

• Implementation fidelity was low:
  • Only ~67% of online webinars attended
  • 52% of modules completed
  • 52% of monthly support calls attended
  • 63% of required data submissions completed
• Barriers to implementation included:
  • Staff turnover
  • Competing demands
  • Limited leadership engagement
• Suggested that low uptake and motivation likely limited the effect, in contrast to earlier pilot studies where sites were self-selected and highly motivated 

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Summary Conclusion:

This large, randomised pragmatic trial found that providing remote training and support for INTERACT implementation across U.S. nursing homes did not reduce hospitalisation or ED visit rates, except for a modest reduction in potentially avoidable hospitalisations, which did not survive statistical correction. The limited implementation fidelity, variable engagement, and lack of in-person support likely undermined effectiveness. The study suggests that successful QI programs like INTERACT require strong leadership, motivated staff, and active, localised support—not just passive dissemination of tools and webinars.

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