Life In The Slower Lane

Here is the structured PICO analysis for the thirty-ninth article you uploaded:

✅ Full Title (verbatim and exact):

“Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial”Martin RS, Hayes BJ, Hutchinson A, et al.Journal of the American Medical Directors Association (2019); 20(10):1318–1324DOI: https://doi.org/10.1016/j.jamda.2019.06.017

📄 Type of Article:

Cluster randomized controlled trial (RCT)

🔍 PICO Analysis:

Population:

• 326 permanent residents of 6 residential aged care facilities (RACFs) in Northern Metropolitan Melbourne, AustraliaMedian age: 88 yearsHigh prevalence of dementia (46–51%), multimorbidity, and frailtyParticipants included all residents for whom informed consent (or proxy consent) was obtained 

Intervention:

Goals of Patient Care (GOPC) medical treatment orders

• A structured shared decision-making process led by a geriatrician, incorporating:

  • Existing advance care planning (ACP) documentsResident/family preferencesCompletion of a medical treatment order form

  GOPC forms translated preferences into actionable treatment orders, including:

  • Levels of intervention (Goals A–D)Resuscitation statusTransfer to hospital preferencesEnd-of-life care plan initiation 

Comparator:

• Usual care, which included existing RACF ACP practicesNo GOPC forms or formal medical treatment orders in placeACPs were often resident- or family-initiated and varied in completeness and clinical utility 

Outcome:

1. Person-centred outcomes:

• Preferred place of death:

  • Residents in the intervention group were significantly more likely to die in the RACF at 6 monthsIn-RACF mortality relative risk: 2.19 (95% CI: 1.16–4.14, P = .016)Hospital deaths decreased but not significantly at 6 or 12 months 

• Treatment preference alignment
:

• Over 90% of residents chose limited or symptom-focused care (Goals C1 or C2)31% opted for no further hospital transfers, indicating success in eliciting and recording care preferences 

2. Process outcomes:

• ED visits and emergency hospitalisations:

  • 12-month reduction was statistically significantIncidence Rate Ratio (IRR) = 0.63 (95% CI: 0.41–0.99; P = .044), representing ~40% reductionReductions at 3 and 6 months were not statistically significant

• Total hospital bed-days
:

• Reduced at all time points in intervention group, but not statistically significant

• Advance care planning documentation
:

• Intervention group had higher rates of MEPOA nomination (63% vs 47%, P = .01)No significant difference in formal ACP or legal documentation presence 

3. Health system outcomes:

• Avoided ED and inpatient admissions imply potential cost savingsSupports future implementation of GOPC as a scalable intervention to reduce acute care use in aged careHighlights need for clinician time and organisational buy-in for implementation 

Summary Conclusion:

This cluster RCT found that the Goals of Patient Care (GOPC) intervention, which embeds shared decision-making into medical treatment orders for aged care residents, significantly reduced hospital transfers and ED visits after 12 months and increased the likelihood of dying in place. GOPC was more effective than ACP alone, particularly in aligning care with resident preferences and improving communication. The study supports broader adoption of GOPC frameworks in RACFs, especially under new legislation that limits ACP to those with decision-making capacity. GOPC provides a structured, clinically meaningful way to guide treatment at times of deterioration.