Here is the standardised PICO analysis for the sixty-second uploaded article:
Full Title
Nursing Home Characteristics Associated with Implementation of an Advance Care Planning Video Intervention
Authors: Lacey Loomer, Ellen McCreedy, Emmanuelle Belanger, et al.
Journal: Journal of the American Medical Directors Association, 2019; 20(7):804–809.e1
DOI: 10.1016/j.jamda.2019.01.133
Type of Study
Cross-sectional analysis of nursing home-level variation in adherence to an advance care planning (ACP) video intervention as part of the PROVEN pragmatic trial
PICO Summary
Population (P)
- 119 U.S. nursing homes enrolled in the PROVEN trial (intervention arm)
- Resident subgroups: short-stay (<100 days) and long-stay (≥100 days)
- Most facilities were part of two large for-profit chains; majority of Champions were social workers
Intervention (I)
- ACP Video Education Program:
- 5 short (~6–10 min) videos offered via tablet or online
- Champions (typically social workers) tasked with offering the videos to:
- Short-stay residents within 14 days of admission
- Long-stay residents every 6 months
- Structured video status reports (VSRs) tracked whether a video was offered or shown
- Monthly check-in calls supported champions with implementation feedback and guidance
Comparison (C)
- Compared implementation fidelity (offer and show rates) between nursing homes with different:
- Star ratings
- Staff turnover
- Champion engagement (e.g. check-in call attendance)
- Resident composition (age, cognition)
- Staffing and quality indicators
Outcomes (O)
Primary outcomes (measured via EMR-integrated VSRs):
- Offer rate (% of eligible residents offered a video)
- Show rate (% of eligible residents who viewed a video)
Results:
- Median offer rates:
- Short-stay: 80% (range 0–100%)
- Long-stay: 58%
- Median show rates:
- Short-stay: 10%
- Long-stay: 13%
- Ranges for both from 0% to ~80%
Regression analysis findings:
- Higher CMS star rating (2–5 stars) significantly associated with higher offer rates for both resident groups (p < 0.01)
- Check-in call attendance positively associated with higher offer and show rates in long-stay residents
- Champion turnover, staffing levels, bed size, cognitive status, and payer mix not consistently associated with offer/show rates
Findings Summary
This study highlights substantial variation in implementation of the same intervention across nursing homes. Key insights include:
- Better-quality facilities (higher star ratings) had greater success integrating the video program into routine care
- Champion engagement via check-in calls played a crucial role in maintaining implementation fidelity
- Lower-rated facilities may lack the capacity, leadership, or organisational support to sustain even low-burden interventions without targeted support
- Findings emphasise the need for tailored implementation strategies for under-resourced homes in future trials
Conclusion
Even simple ACP interventions like video education require ongoing support, local leadership buy-in, and context-aware facilitation to be implemented consistently. Without this, there is risk of exacerbating care disparities between higher- and lower-performing nursing homes in pragmatic research and practice improvement initiatives .
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