Advance care planning increased with patient-facing interventions
Outreach by a health navigator significantly increased completion of advance care planning forms compared to patient portal messages and mailed materials, according to a study of 5,810 seriously ill patients across 50 primary care clinics.
Implementing an automated patient-facing intervention for advance care planning increased use of advance directives and orders regarding life-sustaining treatment, a study in two health systems found.
The cluster-randomized trial compared different advance care planning approaches among 5,810 seriously ill adult patients across 50 primary care clinics who did not have a prior advance directive or Physician Orders for Life-Sustaining Treatment (POLST) form in the electronic health record (EHR). The primary outcome was presence of an advance directive or POLST form in the EHR at 12 and 24 months. The secondary outcome was documented advance care plan discussions and health care utilization over 24 months.
Clinics were randomly assigned to one of three intervention groups. The group 1 intervention included a message through the EHR patient portal with a link to an advance directive and a mailed message with an advance directive. Group 2 got the group 1 materials plus a link to the PREPARE website and a mailed pamphlet with information about the website. Group 3 received the group 2 materials plus health navigator outreach. The study was published Nov. 25 by Annals of Internal Medicine.
By 24 months, 13.7% (95% CI, 12.1% to 15.3%) of patients in group 1, 12.7% (95% CI, 11.2% to 14.1%) in group 2, and 19.8% (95% CI, 18.1% to 21.5%) in group 3 had a documented advance directive or POLST form. After adjustment for patient and site factors, group 3 patients were more likely to have completed these documents compared with group 1 or group 2 (adjusted differences, 4.6% [95% CI, 0.8% to 8.4%] and 5.5% [95% CI, 0.8% to 10.2%], respectively). Documented advance care plan discussions were also higher in group 3 (adjusted differences, 4.7% [95% CI, 1.4% to 7.9%] and 4.2% [95% CI, 1.1% to 7.2%] vs. groups 1 and 2, respectively). Health care utilization did not differ by group.
The researchers noted that the study's advance care plan interventions work within existing clinical workflows, can be adjusted for desired intervention frequency, and can serve as a foundation for developing more intensive interventions in health systems.
“The patient-facing, EHR-based interventions demonstrated increased pre–post [advance directives] and POLST form integration into the EHR and increased clinician documentation of [advance care planning] discussions,” the authors wrote.
An editorial noted that the study contributes to the ongoing debate about the cost of focusing on improving advance care planning. “From this study and others, it seems clear that improvements in [advance care planning] are achievable—but at what cost?” asked the editorial. “Given the modest effect that was seen, the cost-effectiveness of such an intervention may depend on existing resources,” the editorialist said, noting that adding a navigator for advance care planning may be hard to justify without a proven effect on health care utilization.