Life In The Slower Lane

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

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Full Title (verbatim and exact):

“Effects of two feedback interventions on end-of-life outcomes in nursing home residents with dementia: A cluster-randomized controlled three-armed trial”

Boogaard JA, de Vet HCW, van Soest-Poortvliet MC, Anema JR, Achterberg WP, van der Steen JT

Palliative Medicine (2018); 32(3):693–702

DOI: https://doi.org/10.1177/0269216317750071

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Type of Article:

Cluster-randomised controlled trial (three-arm)

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PICO Analysis:

Population:

• Bereaved family caregivers of nursing home residents with dementia
• 18 Dutch nursing homes with psychogeriatric units (1790 beds)
• Inclusion: residents with dementia who stayed ≥16 days in the last month of life, and a family caregiver who could complete post-mortem questionnaires in Dutch 

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Intervention:

Two types of feedback interventions based on the End-of-Life in Dementia (EOLD) instruments:

1. Generic feedback: aggregated, anonymous family feedback scores benchmarked against a national norm
   • Feedback reports included statistically flagged strengths/deficits and improvement suggestions
2. Patient-specific feedback: individual family caregiver feedback reports discussed in team meetings
   • Accompanied by practical suggestions but no benchmarking

Both strategies encouraged multidisciplinary teams to discuss results and implement improvement actions 

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Comparator:

• No feedback (control group): nursing homes received feedback only after the study ended

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Outcome:

1. Person-centred outcomes:

• Perceived quality of care (EOLD–Satisfaction With Care, range 10–40)
• Comfort in dying (EOLD–Comfort Assessment in Dying, range 14–42)
• Subscales: physical distress, dying symptoms, emotional distress, well-being 

2. Process outcomes:

• Generic feedback group:
  • 5 of 6 homes discussed results; only 4 implemented any actions
  • Most feedback was positive (flagged green), leading to little incentive for improvement
  • Associated with a statistically significant decline in perceived quality of care (–2.41 adjusted; 95% CI: –4.07 to –0.76) 
• Patient-specific feedback group:
  • Implemented more improvement actions (n=33) than generic group (n=10)
  • Showed a non-significant trend toward better comfort (EOLD-CAD: +1.88; 95% CI: –0.34 to 4.10)
  • Significant improvement in the Dying Symptoms subscale (+1.18 adjusted; 95% CI: 0.38 to 2.00) 

3. Health system outcomes:

• Neither intervention significantly changed the overall comfort or burden of dying
• Implementation was limited due to:
  • High baseline satisfaction scores (little room to improve)
  • Minimal documentation of follow-through actions
  • Limited staff involvement beyond physicians
• The authors caution that positive feedback might reduce improvement motivation, and that multidisciplinary engagement and repeated feedback cycles are likely necessary 

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Summary Conclusion:

This trial found that generic feedback may paradoxically lower perceived care quality, potentially due to reassurance from already favourable scores. Patient-specific feedback showed modest improvement in symptom comfort, particularly in the final days of life, but overall effects were small. Active team participation, structured goal setting, and regular follow-up may be required to translate feedback into meaningful improvements. These findings are relevant for palliative quality improvement initiatives using family-based feedback in residential aged care.

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