Grand Rounds December 8, 2023: A Pragmatic Randomized Trial of the Jumpstart Intervention to Promote Communication about Goals of Care for Hospitalized Patients with Serious Illness (Ruth Engelberg, PhD; Erin Kross, MD; Robert Lee, MD, MS)

Posted on by Elizabeth Mccamic

Speakers

Ruth Engelberg, PhD
Research Professor of Medicine
Division of Pulmonary, Critical Care and Sleep Medicine
University of Washington

Erin Kross, MD
Associate Professor of Medicine,
Division of Pulmonary, Critical Care and Sleep Medicine
University of Washington

Robert Lee, MD, MS
Assistant Professor of Medicine
Division of Pulmonary, Critical Care and Sleep Medicine
University of Washington

Keywords

Jumpstart, Advanced Planning, Goals of Care

Key Points

  • Researchers know that goals of care discussions between patients and clinicians are associated with important patient and family outcomes. And yet goals of care discussions and their documentation remain a shortcoming in many health systems.
  • The Jumpstart intervention is a communication-priming intervention. It has been studied in prior contexts in a PCORI trial and a pilot inpatient trial where the intervention increased goals of care discussions from 8% to 21%.
  • For the Jumpstart trial, a number of refinements were made to make it more pragmatic, including the creation of Jumpstart using EHR data rather than patient or family member surveys, delivering the intervention to clinicians only, automated population of Jumpstart guide fields, and automated Jumpstart delivery to clinicians by email.
  • The research question Jumpstart set out to answer is can a patient-specific, clinician-facing communication priming intervention with discussion prompts effectively promote goals of care discussions between clinicians and hospitalized older adults with serious illness?
  • Jumpstart is a pragmatic randomized trial of Jumpstart compared to usual care. It utilized a waiver of consent; all eligible patients were randomized, and randomization was stratified by hospital and history of dementia at 3 hospitals in University of Washington system.
  • Patients who were eligible had been hospitalized at least 12 hours but no more than 96 hours, age 55 and older with at least one Dartmouth Atlas chronic condition, or they were age 80 or older. The Jumpstart Guide was delivered to members of the primary hospital team on day of randomization via a secure email with a reminder message via pager.
  • The primary outcome was the proportion of patients with EHR-documented goals of care discussion within 30 days of randomization. Goals of care discussions were defined as discussions about overarching goals for medical care but going beyond “just code status” (e.g. DNR/DNI). The goals of care discussions were identified by a natural language processing (NLP) called BERT and screened human abstraction.
  • The study team trained and validated the NLP model by adjudicating 2,500 notes, and compared human decisions with NLP decisions to come up with an assessment with how NLP preformed. In order to classify a patient with goals of care conversation, the study used the NLP to screen the records and pull out excerpts of EHR that had high probability to contain a goals of care conversation and then conducted a human review. EHR passages were adjudicated in pseudo-random order, blinded to patient ID.
  • Jumpstart also obtained secondary outcomes from the EHR, including ICU admissions, ED visits, palliative care consultation, ICU and hospital-free days, death and hospital readmission within 7 days of discharge
  • Among hospitalized older adults with serious illness, Jumpstart found that a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals of care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients.
  • Jumpstart provides evidence that a low-touch intervention can nudge clinicians to change behavior. Overall prevalence of goals of care discussions is low suggestions opportunity for improvement. Jumpstart may be useful in enhancing equity in serious illness communication among racially or ethnically minoritized patients.

Learn more

Read more in JAMA and a JAMA editorial.

Discussion Themes

-Within individual physicians, did you see an increase in goals of care discussions? We have not looked within clinician practices for documentation. In some previous trials we have randomized at the clinician level. What’s hard is that patients have a number of different physicians. When we sent out the jumpstart we sent it to the entire team, from interns to attendings. We don’t have much data on the overall effect on individual physicians behavior.

-Were you to do this again would you use BERT again or go in a different direction? BERT was state of the art in 2018 and out preformed all other NLPs at the time. The same family of deep learning models is still considered state of the art. The key thing with these models is that they have gotten bigger to accommodate the language. We could possibly take out the training phase.

–What is the concern about prompt fatigue in these settings? It is something we are thinking about a lot in the outpatient trial. Clinicians could receive prompts on an almost daily basis. We are limiting it so clinicians can only receive prompts x times day.

Tags

#pctGR, @Collaboratory1