Original Study
Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial

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Abstract

Objectives

The “Goals of Patient Care” (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF).

Design

The study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences.

Setting and participants

The study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained.

Measures

The primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates.

Results

More than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016).

Conclusions and implications

In the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.

Section snippets

Goals of Patient Care

The GOPC form (Appendix 1) is a document used to record medical treatment plans for residents of RACF in the event of clinical deterioration. It considers the current medical condition as well as the residents' preferences and any prior advance care planning. As it is specifically for RACF residents, it identifies whether residents are open to hospital transfer for treatment escalation. The form is completed by a medical physician with the resident or their substitute medical decision maker, or

Study Design

The study design was an unblinded prospective cluster randomized controlled trial evaluating the effects of the implementation of the GOPC medical treatment orders for RACF residents. The clusters were defined as the individual RACF, which were then organized into cluster pairs and randomized. Clustering was used to prevent cross-contamination between sites influencing the results. Written informed consent was obtained for RACF participation and to gain access to the local health care services

Participants

The residents from the 3 Intervention RACFs were combined for analysis, as were the residents from the 3 Control RACFs. The total potential study population was 445 residents, with 418 fitting inclusion criteria and 326 continuing to randomization. In the 6 RACFs involved, the mean study participation rate was 78%. In total, at study commencement, there were 145 residents in the Control Group and 181 in the Intervention Group.

The CONSORT participant flow diagram indicates the number of

Discussion

The GOPC intervention was found to be superior to advance care planning documents alone in the RACF population with regard to preventing ED visits and emergency admissions 12 months post implementation, aligning with previous studies examining medical treatment orders.29, 30 High hospitalization rates of RACF residents have detrimental effects on residents' quality of life as well as economic consequences for health services, and so interventions to decrease these rates are important for all

Conclusions and Implications

In RACFs in Australia, GOPC medical treatment orders had a positive effect on the hospitalization rates and preferred place of death of RACF residents without increasing mortality. The implications of this are that RACF and health services would benefit from GOPC being introduced to improve resident outcomes. In Victoria, new legislation allows only those with decision-making capacity to complete advance care plans, no longer allowing substitute medical decision makers to complete them on their

Acknowledgements

The authors acknowledge Northern Health Foundation for a Small Research Grant for the study, and the Northern Health Aged Care Research Department and the University of Melbourne for research scholarships for the principal researcher. There were no study sponsors further to these grants. The researchers are independent from the funders.

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    The authors declare no conflicts of interest.

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