A strategy for advance care planning (ACP) that included automated outreach from staff who contacted patients to offer assistance significantly boosted the number of patients who completed documentation outlining their wishes in times of serious illness, research finds.
People with serious illnesses should discuss their medical care wishes with families and doctors, said Dr. Neil Wenger, professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA and the study’s senior author. But these conversations are not always easy, particularly for primary care doctors who are busy with other clinical concerns and have limited time.
“Nearly everyone will become seriously ill at some time, and creating better structures to stimulate advance care planning means that people will be more likely to have earlier conversations leading to medical care aligned with goals,” added Dr. Anne Walling, also a professor of medicine in the same division and first author of the paper.
The findings are published in the peer-reviewed journal Annals of Internal Medicine
To determine the most effective way to prompt patients to complete a plan, the researchers compared three ACP interventions across healthcare clinics at UCLA, University of California, San Francisco and University of California, Irvine. The approximately 8,000 patients who were part of the interventions were seriously ill, had a primary care physician within one of the university health systems, and had seen their doctor at least twice over the prior year. The main outcome of interest was whether the interventions led patients to complete an advance directive at 12 months and 24 months.
One intervention included a message sent through the patient’s electronic health record portal that included a link to an advanced directive and a mailed message. The message outlined the importance of having an advance directive and the steps toward completion and discussion with one’s physician. The second intervention included the same elements as the first but added a link to PrepareForYourCare.org, which provides information to assist in making informed medical decisions, and guides advance directive completion. The third incorporated the two interventions plus health navigator outreach for assistance. All physicians in the clinics received ACP training.
They found that after 24 months 13.7% of patients in the first group, 12.7% of patients in group two, and 19.8% in the third group had completed an advance directive that was available in the electronic health record, indicating that the automatic outreach to seriously ill patients was effective in prompting ACP.
The addition of outreach from the health navigator prompted more advanced care discussions than did the other two.
“Health systems can put into place an automated mechanism to promote advance care planning conversations between patients and doctors within the existent clinical workflow,” Wenger said. “A health navigator can augment advance care planning conversations by contacting patients before their doctor visit.”
The study was conducted in three University of California health systems, so the results may not be applicable to other systems, the researchers note. While the patient sample was diverse, the trial did not include a control group.
The next step is to implement the intervention with a broader group of patients as well as to other healthcare systems, Walling said. “The advance care planning intervention can be a foundation on which to build more sophisticated conversations and decision making,” she said.
Study co-authors, all from UCLA, UCSF and UCI, are Dr. Rebecca Sudore, Dr. Lisa Gibbs, Dr. Maryam Rahimi, Ron Hays, Chi-hong Tseng, Kanan Patel, Katherine Santos, Fernando Javier Sanz Vidorreta, Aaron Chau, Juan Carlos Antonio Lopez, Jamie Anand, G. Rick Marshall, Anna DePaolis-Dickey, Kirsten Buen, Dr. Douglas Bell, Dr. Christine Ritchie, and Victor Gonzalez.
The study was funded through a Patient-Centered Outcomes Research Institute (PCORI) award (PLC-1609-36291).
