Nervous System Diseases

Behaviors and Mental Disorders

All Conditions

Urinary Tract, Sexual Organs, and Pregnancy Conditions

Respiratory Tract (Lung and Bronchial) Diseases

Symptoms and General Pathology

Heart and Blood Diseases

Digestive System Diseases

Rare Diseases

Dementia

Kidney Diseases

Lung Diseases, Obstructive

Pulmonary Disease, Chronic Obstructive

Kidney Failure, Chronic

Heart Failure

End Stage Liver Disease

Lung Diseases

Liver Diseases

Lung Diseases, Interstitial

Renal Insufficiency

Respiratory Tract Diseases

Chronic Disease

Disease Attributes

Gastrointestinal Diseases

Urologic Diseases

Urogenital Diseases

Female Urogenital Diseases

Pregnancy Complications

Female Urogenital Diseases and Pregnancy Complications

Male Urogenital Diseases

Renal Insufficiency, Chronic

Liver Failure

Hepatic Insufficiency

Chronic Graft Versus Host Disease

First stage: No patient engagement. Low intensity clinician training. Second stage (responders only): No patient engagement and high intensity clinician training.

Second stage (non-responders only): High patient engagement and high intensity clinician training.

First stage: No patient engagement. Low intensity clinician training. Second stage (responders only): No patient engagement and high intensity clinician training.

Second stage (non-responders only): Low intensity patient engagement and high intensity clinician training.

First stage: Low intensity patient engagement. Low intensity clinician training.

Second stage (responders only): No patient engagement and high intensity clinician training.

Second stage (non-responders only): High patient engagement and high intensity clinician training.

First stage: Low patient engagement. Low intensity clinician training. Second stage (responders only): No patient engagement and high intensity clinician training.

Second stage (non-responders only): Low intensity patient engagement and high intensity clinician training.

A "booster" of the established LSTDI implementation strategy. Clinicians will be presented with summary written/electronic materials on the LSTDI developed for the study. Online training options and when and how to complete goals of care conversations and documentation will be highlighted.

Clinician Implementation Strategy Stage 1: low intensity clinician training

This includes two components:

1. Team facilitation to help the primary care team (advance practice provider, nurse, social worker) work together to create roles and responsibilities for accomplishing goals of care conversations with patients
2. A patient list "trigger" of patients potentially eligible for goals of care conversations (the patient study population) will be sent to the primary care clinicians.

Clinician Implementation Strategy Stage 2: high intensity clinician training

Patients will be sent information about goals of care conversations, including the PREPARE website.

Low patient engagement

Patients will be sent information about goals of care conversations, including the PREPARE website. Follow-up phone calls to discuss goals of care conversations and the PREPARE website will be made.

High patient engagement

David Bekelman, MD MPH

Anne M Walling, MD PhD

The long term goal is to improve quality of care in Veterans with serious illnesses by aligning medical care with Veterans' goals and values. The objective of this study is to use a sequentially randomized trial to determine what implementation strategies are effective to increase early, outpatient goals of care conversations. The study will use interviews with and surveys of medical providers, patients, and caregivers, along with medical record data. This work is significant because it tests ways Veterans can express their goals and preferences for life sustaining treatments and have them honored.

The aims of this study are as follows:

Aim 1. Use a clinician-level SMART in three VA health systems to determine the effectiveness of clinician and patient implementation strategies to improve the occurrence of documented goals of care conversations in Veterans with serious medical illness. Hypothesis 1 (first stage of the SMART): Compared to a low intensity clinician strategy alone, a low intensity clinician and patient strategy will lead to increased documentation of goals of care conversations. Hypothesis 2. Among those who do not respond to low intensity strategies, compared to a high intensity clinician strategy paired with a low intensity patient strategy, a high intensity clinician and patient strategy will lead to increased documentation of goals of care conversations.

Aim 2a. Identify the sequence of implementation strategies that leads to the overall greatest increase in documentation of goals of care conversations. Aim 2b (exploratory). Identify patient and clinician characteristics that modify the effect of sequences of implementation strategies on documentation of goals of care conversations.

Aim 3. Understand clinician and patient implementation strategy success or failure using a mixed method evaluation involving clinicians, leaders, patients, and caregivers.

Sequential multiple-assignment randomized clinical trial (SMART)

The primary outcome of goals of care conversation notes is determined by whether notes are entered into the electronic health record. The data manager queries the VA corporate data warehouse to determine if these notes are completed. Because the data manager can see who wrote the notes, the data manager is not blinded. However, the investigators do not expect the data manager to judge whether the notes were completed.

Goals of Care Conversations Study

Improving Implementation of Outpatient Goals of Care Conversations for Veterans With Serious Illness

Amongst patients attributed to a clinician who was randomized in Stage 2, whether or not a goals of care conversation note was written during Stage 2.

Amongst all patients in the study, whether or not a goals of care conversation note was written during the study.

Amongst all patients in the study, whether or not a goals of care conversation note was written during stage 1

Spots Global Cancer Trial Database for clinician implementation strategy stage 2: high intensity clinician training