Helping Seniors Plan for Posthospital Discharge Needs Before a Hospitalization Occurs: Results from the Randomized Control Trial of PlanYourLifespan.org

Study Design and Randomization

To test PYL, a 2-armed (attention control [AC] and PYL intervention), parallel, randomized controlled trial was conducted. Participants were randomly assigned to 1 of the 2 conditions via a pregenerated central randomization list using equal (1:1) allocation and random permuted block design to ensure relatively equal allocation throughout the study. The AC condition exposed participants to the National Institute on Aging-sponsored website, Go4Life.nia.nih.gov, an educational website on physical activity for seniors. This website has comparable design and layout to PYL but does not include information about advanced planning. The AC condition controlled for the possibility that regular contact with the study team may improve outcomes in participants randomized to the intervention website.

The trial was conducted from October 2014 to September 2015 in Chicago, Illinois; Fort Wayne, Indiana; and Houston, Texas. Inclusion criteria were as follows: age 65 and older, English-speaking, scoring ≥4 questions correctly on the Brief Cognitive Screen,¹⁴ and current self-reported use of a computer or smartphone with internet. Participants were excluded if they had previously participated in the focus groups or beta testing of the PYL website. Community-based patient partners/stakeholders drove subject recruitment in their communities through word of mouth, e-mail bursts, newsletters, and flyers. At the Area Agency on Aging and community centers where services such as food vouchers and case management are provided, participants were recruited on-site and given study information. At the clinical sites, staff referred potential participants. Study materials such as flyers and information sheets were also located in the clinic waiting rooms. The Villages, nonprofit, grassroots, membership organizations that are redefining aging by being a key resource to community members wishing to age in place, heavily relied on electronic recruitment using their regular e-newsletters and e-mail lists to recruit potential participants. Potential subjects were also recruited by distributing flyers at local senior centers and senior housing buildings. Interested seniors contacted research staff who explained the study and assessed their eligibility. If eligible, subjects were scheduled for a face-to-face interview.

At the face-to-face encounter, all study subjects completed a written consent, answered baseline questions, and were randomized to either arm. Next, research staff introduced all study subjects to the website to which they were randomized and provided instructions on its use. Staff were present to assist with questions as needed on navigation but did not assist with decision making for either website. A minimum of 15 minutes and a maximum of 45 minutes was allotted for navigating either website. After navigating their website, participants were administered an immediate in-person posttest survey. One month and 3 months after the face-to-face encounter, research staff contacted all study participants over the phone to complete a follow-up survey. Staff attempted to reach participants up to 3 times by phone. Data were entered into Research Electronic Data Capture survey software.¹⁵ This study was approved by the Northwestern University Institutional Review Board.

Understanding of Posthospital Discharge and Home Services

As part of the larger trial, which included behavioural outcomes that will be reported elsewhere, we sought to explore the effects of PYL on participants’ knowledge and understanding of posthospital discharge and home services (UHS). Participants were asked to respond to 6 questions at baseline, immediate posttest, and at the 1- and 3-month follow-up time points. Knowledge items were developed by the study team in conjunction with the patient/partner stakeholders. UHS scores were calculated as the sum of the 6 questions (each scored 0 if incorrect and 1 if correct) with a possible range of 0-6.

Covariates

Demographic information, self-reported health, importance of religion, and existence of a power of attorney, living will, advanced directive (eg, Physician Orders for Life-Sustaining Treatment) were obtained via self-report. Participants were asked about their general and social self-efficacy using the validated Self-efficacy Scale¹⁶ and their social support using the Lubben Social Network Scale–6.¹⁷ Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine–Short Form.¹⁸ To measure burden of disease, participant comorbidities were measured using a nonvalidated 9-item dichotomous response condition list, which included some items adapted from the Charlson Comorbidity Index and the Elixhauser Comorbidity Index.

Statistical Analysis

Data analysis included all available data in the intention-to-treat dataset. As UHS was collected at multiple time points up to 3 months postintervention, we employed linear- mixed modeling with random participant effect and fixed arm, time, and time-by-arm interaction terms. The time-by-arm interaction allows for comparison of UHS slopes (or trajectories) across arms. Analyses explored multiple potential covariates, including current utilization of services, physical function, comorbidities, social support, health literacy, self-efficacy, and sociodemographics. Those covariates found to have a significant association (P < 0.05) with outcome were considered for inclusion in the overall model selection process. Ultimately, we developed a final parsimonious, adjusted longitudinal model with primary predictors of time, arm, and their interaction, controlling for only significant baseline variables following a manual backward selection method. All analyses were conducted in SAS software (version 9.4, copyright 2012, The SAS Institute Inc., Cary, North Carolina).