Transfers Redux

Last week, I praised MedPAC for devoting an entire chapter of its June report to Congress to strategies for decreasing transfers from nursing homes to acute care hospitals. Some of the pilot projects reported had successfully reduced potentially burdensome, unwanted, and costly hospitalizations of the frail, very elderly population who live in nursing homes. So I was dismayed to read this week about a follow-up study to one of these pilots, a large, randomized controlled trial—that failed to produce any change whatsoever.

Robert Kane, the lead author, who sadly passed away several months before the publication of the article, was a prolific, influential, and thoughtful scholar of geriatrics in general and long term care in particular; Joseph Ouslander, the senior author, is likewise a giant in the field of geriatrics, who has similarly focused much of his research on long term care. Their report of the INTERACT (Intervention to Reduce Acute Care Transfers) trial, begins by observing that the core principles underlying the study are 1) early recognition and proficient management of acute conditions has the potential to prevent the progression of disease to the point where hospitalization is deemed necessary; 2) the availability of communication, documentation, and decision tools can facilitate care by advanced practice clinicians; and 3) an emphasis on advance care planning, hospice, and palliative care can lead to a higher frequency of “do not hospitalize” orders. Encouraged by the results of their non-randomized pilot study, which demonstrated a 24 percent decrease in all-cause hospitalization among residents of study nursing homes (facilities that volunteered to participate) during the study period compared to baseline, rather than a 6 percent decrease in control facilities, the authors developed a larger, randomized controlled trial to further test the effectiveness of their program. The new program relied on webinars and on line courses to educate nursing home staff and monthly phone calls for support.

The authors reported on 227,140 person-years of observation in 264 nursing homes (randomized to intervention homes, usual care homes, and usual care plus phone contact). Careful statistical analysis revealed no difference in the overall hospital admission rate, the potentially avoidable hospitalization rate, or the rate of Emergency Department visits. No effect at all.
       So was the conclusion I arrived at last week—that people living in nursing homes will forgo hospital care if they are offered a viable alternative and if they (or their surrogate decision-makers) understand both their overall health status and the perils of hospitalization—totally unjustified? Maybe. But maybe not. 

       All we know is that the essence of the project involved educating nursing home personnel to allow them, in principle, to provide more on site care. We know that core staff members, who were obligated by the terms of the study to complete all training modules, in fact only attended 67 percent of the webinars and completed only 52 percent of the online courses; they also only participated in 52 percent of the monthly supportive/feedback phone calls. We know that when push came to shove, either patients or families wanted to go to the hospital, staff members wanted to send them, or both.
       What is far from clear is whether the INTERACT intervention actually improved the quality of care available on site, whether residents and families were aware of and trusted in the improvements, or whether any staff members in fact spoke to patients and families about their state of health, explored goals of care, or offered either hospice or palliative care services. 
       Before we abandon the effort, let’s be sure that the training truly “took,” both in the sense of better capabilities (on the staff side) and of heightened awareness (on the resident and family side). As the authors acknowledge, maybe distance learning is not the right way to teach new knowledge and skills. 
       It's premature to conclude that an approach to decreasing transfers is a failure just because the educational intervention on which it is based was unsuccessful. Before making that leap, we need to be sure that the educational effort truly translates into more advance care planning discussions, more widespread detection and treatment of acute medical conditions, and institution-wide familiarity with the changes. There's still hope that better on site medical care and advance care planning will ultimately reduce the transfer rate from the nursing home to the hospital. But first we need to figure out how to provide reliable, competent, trustworthy nursing home-based treatment and then we need to develop a system of advance care planning that builds on the availability of this kind of treatment.