Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial

Academic Article


  • Background: There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings. Objective: To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs). Design: Cluster randomized implementation trial conducted March 2015–April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites. Participants: One hundred thirty-two providers from PCCTs at 47 VAMCs. Interventions: Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers. Main Measurements: Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates. Key Results: Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement. Conclusion: Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used. Trial Registration: identifier: NCT02383173
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    Author List

  • Bailey FA; Williams BR; Goode PS; Kennedy RE; Redden DT; Kvale E; Bakitas M; Dionne-Odom JN; Burgio KL
  • Start Page

  • 1928
  • End Page

  • 1936
  • Volume

  • 36
  • Issue

  • 7