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Managing uncertain recovery for patients nearing the end of life in hospital: a mixed-methods feasibility cluster randomised controlled trial of the AMBER care bundle

Koffman, J.; Yorganci, E.; Yi, D.; Gao, W.; Murtagh, F.; Pickles, A.; Barclay, S.; Johnson, H.; Wilson, R.; Sampson, L.; Droney, J.; Farquhar, M.; Prevost, T.; Evans, C. J.

Authors

J. Koffman

E. Yorganci

D. Yi

W. Gao

A. Pickles

S. Barclay

H. Johnson

R. Wilson

L. Sampson

J. Droney

M. Farquhar

T. Prevost

C. J. Evans



Abstract

Background
The AMBER (Assessment, Management, Best Practice, Engagement, Recovery Uncertain) care bundle is a complex intervention used in UK hospitals to support patients with uncertain recovery. However, it has yet to be evaluated in a randomised controlled trial (RCT) to identify potential benefits or harms. The aim of this trial was to investigate the feasibility of a cluster RCT of the AMBER care bundle.

Methods
This is a prospective mixed-methods feasibility cluster RCT. Quantitative data collected from patients (or proxies if patients lack capacity) were used (i) to examine recruitment, retention and follow-up rates; (ii) to test data collection tools for the trial and determine their optimum timing; (iii) to test methods to identify the use of financial resources; and (iv) to explore the acceptability of study procedures for health professionals and patients. Descriptive statistical analyses and thematic analysis used the framework approach.

Results
In total, 894 patients were screened, of whom 220 were eligible and 19 of those eligible (8.6%) declined to participate. Recruitment to the control arm was challenging. Of the 728 patients screened for that arm, 647 (88.9%) were excluded. Overall, 65 patients were recruited (81.3% of the recruitment target of 80). Overall, many were elderly (≥80 years, 46.2%, n = 30, mean = 77.8 years, standard deviation [SD] = 12.3 years). Over half (53.8%) had a non-cancer diagnosis, with a mean of 2.3 co-morbidities; 24.6% patients (n = 16) died during their hospital stay and 35.4% (n = 23) within 100 days of discharge. In both trial arms, baseline IPOS subscale scores identified moderate patient anxiety (control: mean 13.3, SD 4.8; intervention: mean 13.3, SD 5.1), and howRwe identified a good care experience (control: mean 13.1, SD 2.5; intervention: mean 11.5, SD 2.1). Collecting quantitative service use and quality of life data was feasible. No patient participants regarded study involvement negatively. Focus groups with health professionals identified concerns regarding (i) the subjectivity of the intervention’s eligibility criteria, (ii) the need to prognosticate to identify potential patients and (iii) consent procedures and the length of the questionnaire.

Conclusions
A full trial of the AMBER care bundle is technically feasible but impractical due to fundamental issues in operationalising the intervention’s eligibility criteria, which prevents optimal recruitment. Since this complex intervention continues to be used in clinical care and advocated in policy, alternative research approaches must be considered and tested.

Citation

Koffman, J., Yorganci, E., Yi, D., Gao, W., Murtagh, F., Pickles, A., Barclay, S., Johnson, H., Wilson, R., Sampson, L., Droney, J., Farquhar, M., Prevost, T., & Evans, C. J. (2019). Managing uncertain recovery for patients nearing the end of life in hospital: a mixed-methods feasibility cluster randomised controlled trial of the AMBER care bundle. Trials, 20(1), Article 506. https://doi.org/10.1186/s13063-019-3612-0

Journal Article Type Article
Acceptance Date Jul 23, 2019
Online Publication Date Aug 16, 2019
Publication Date Aug 16, 2019
Deposit Date Aug 18, 2019
Publicly Available Date Aug 19, 2019
Journal Trials
Print ISSN 1745-6215
Publisher Springer Verlag
Peer Reviewed Peer Reviewed
Volume 20
Issue 1
Article Number 506
DOI https://doi.org/10.1186/s13063-019-3612-0
Keywords Medicine (miscellaneous); Pharmacology (medical)
Public URL https://hull-repository.worktribe.com/output/2477872
Publisher URL https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-019-3612-0
Additional Information Received: 18 April 2019; Accepted: 23 July 2019; First Online: 16 August 2019; : The authors declare that they have no competing interests.
Contract Date Aug 19, 2019

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Copyright Statement
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.






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