Life In The Slower Lane

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

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Full Title (verbatim and exact):

“Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents”

Hickman SE, Unroe KT, Ersek M, et al.

Journal of the American Geriatrics Society (2019); 67(8):1649–1655

DOI: https://doi.org/10.1111/jgs.15927

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Type of Article:

Retrospective observational analysis of a demonstration project (non-randomised intervention study)

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PICO Analysis:

Population:

• 1,482 long-stay residents of 19 Indiana nursing facilities
• Participants were enrolled in the OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care) demonstration project
• Inclusion: Medicare fee-for-service, ≥30 days in facility, not enrolled in Medicare Advantage
• Mean age: 79.2 years; 67.5% female; 72.5% white; varied cognitive and functional status 

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Intervention:

• Systematic advance care planning (ACP) facilitated by specially trained nurses, including:
  • Use of Indiana Physician Orders for Scope of Treatment (POST)
  • Regular engagement with residents and families to document goals of care
  • ACP discussions triggered monthly or upon changes in condition 

Residents were categorised into three groups:

1. Comfort Measures/DNH (Do Not Hospitalize)
2. ACP with no hospitalization limits
3. No ACP documented

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Comparator:

• Residents without documented ACP or hospitalization limitations, i.e., “No ACP” group
• Comparisons also made between DNH vs limited intervention vs full code/No ACP

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Outcome:

1. Person-centred outcomes:

• Not directly assessed in this study
• ACP documentation reflects resident preferences; potential person-centred outcomes include:
  • Dying in place
  • Avoiding unwanted hospitalization
  • Concordance with treatment goals

2. Process outcomes:

• Primary outcome: Rate of potentially avoidable hospitalisations (PAHs) per 1,000 resident-days
• Secondary outcome: Rate of all-cause hospitalisations per 1,000 resident-days

Key findings:

• Unadjusted data:
  • DNH/Comfort Measures group had significantly lower hospitalisation rates:
    • PAH: 0.4 vs 0.9 (No ACP)
    • All-cause: 1.5 vs 2.7 (No ACP) 
• After adjustment for age, cognition, and function:
  • Differences were no longer statistically significant
  • Age, cognitive impairment, and lower ADL function predicted lower hospitalisation rates independently of ACP status 

3. Health system outcomes:

• Overall hospitalisation rates in OPTIMISTIC were lower than average, potentially due to other components:
  • Enhanced on-site medical care
  • Transition support
  • Payment reform incentives
• ACP alone did not account for reduced hospitalisations in multivariable models, highlighting the need to evaluate complex, multicomponent interventions holistically 

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Summary Conclusion:

In this evaluation of the OPTIMISTIC demonstration project, systematic advance care planning (ACP) was associated with lower unadjusted rates of hospitalization, especially among residents with documented preferences for comfort care or DNH. However, after controlling for resident age, cognition, and function, the effect of ACP on hospitalization rates was no longer statistically significant. This suggests that ACP alone may not explain hospitalisation decisions—other factors such as facility capacity, illness severity, and culture of care play key roles. Nonetheless, ACP remains valuable for ensuring goal-concordant care and may be most effective when combined with broader system-level interventions.

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