Impact of a prospective feedback loop aimed at reducing non-beneficial treatments in older people admitted to hospital and potentially nearing the end of life. A cluster stepped-wedge randomised controlled trial

Objectives: 

To investigate if a prospective feedback loop that flags older patients at risk of death can reduce non-beneficial treatment at end of life. 

Design: 

Prospective stepped-wedge cluster randomised trial with usual care and intervention phases. 

Setting: 

Three large tertiary public hospitals in south-east Queensland, Australia.  

Participants: 

14 clinical teams were recruited across the three hospitals. Teams were recruited based on a consistent history of admitting patients aged 75+ years, and needed a nominated lead specialist consultant. Under the care of these teams, there were 4,268 patients (median age 84 years) who were potentially near the end of life and flagged at risk of non-beneficial treatment. 

Intervention: 

The intervention notified clinicians of patients under their care determined as at-risk of non-beneficial treatment. There were two notification flags: a real-time notification and an email sent to clinicians about the at-risk patients at the end of each screening day. The nudge intervention ran for 16–35 weeks across the three hospitals. 

Main outcome measures: 

The primary outcome was the proportion of patients with one or more intensive care unit (ICU) admissions. The secondary outcomes examined times from patients being flagged at-risk. 

Results: 

There was no improvement in the primary outcome of reduced ICU admissions (mean probability difference [intervention minus usual care] = −0.01, 95% confidence interval −0.08 to 0.01). There were no differences for the times to death, discharge, or medical emergency call. There was a reduction in the probability of re-admission to hospital during the intervention phase (mean probability difference −0.08, 95% confidence interval −0.13 to −0.03). 

Conclusions: 

This nudge intervention was not sufficient to reduce the trial’s non-beneficial treatment outcomes in older hospital patients. Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).