Sudore Rebecca L, Knight Sara J, McMahan Ryan D, Feuz Mariko, Farrell David, Miao Yinghui, Barnes Deborah E
San Francisco Veterans Affairs Medical Center, San Francisco, California, USA; Division of Geriatrics, University of California, San Francisco, California, USA.
Department of Psychiatry, University of California, San Francisco, California, USA; Health Services Research & Development Service, Veterans Administration, Washington, D.C., USA.
J Pain Symptom Manage. 2014 Apr;47(4):674-86. doi: 10.1016/j.jpainsymman.2013.05.023. Epub 2013 Aug 21.
We have reconceptualized advance care planning (ACP) as a multistep process focused on preparing patients with skills needed for communication and in-the-moment decision making.
To operationalize this paradigm, we created an easy-to-use ACP website (prepareforyourcare.org) based on a theoretical framework of behavior change and pilot-tested its efficacy to engage older adults in ACP.
At baseline and 1 week after viewing the PREPARE website, we assessed behavior change in ACP by using a validated survey that includes Process Measures (knowledge, contemplation, self-efficacy, and readiness, 5-point Likert scales) and Action Measures (yes/no whether an ACP behavior was completed). We also assigned participants into behavior change stages (i.e., precontemplation, contemplation, preparation, action, maintenance) and determined the percentage of participants who moved from precontemplation at baseline to higher stages at 1 week. We also assessed PREPARE ease-of-use (10-point scale, 10 being the easiest). Changes were assessed with Wilcoxon signed rank sum tests and McNemar's tests.
Mean age of the participants was 68.4 years (SD 6.6), and 65% were nonwhite. Behavior Change Process Measures average Likert scores increased from 3.1 (0.9) to 3.7 (0.7), P < 0.001. Action Measures did not change significantly. However, precontemplation significantly decreased for most actions (e.g., talking to doctor about desired medical care, 61% to 35%, P < 0.003), with a mean decrease of 21% (range, 16%-33%). PREPARE was rated a nine of ten (±1.9) for ease-of-use.
A new, patient-centered ACP website that focuses on preparing patients for communication and decision making significantly improves engagement in the process of ACP and behavior change. A clinical trial of PREPARE is currently underway.
我们将预先护理计划（ACP）重新定义为一个多步骤过程，重点是让患者掌握沟通和即时决策所需的技能。
为了将这一模式付诸实践，我们基于行为改变的理论框架创建了一个易于使用的ACP网站（prepareforyourcare.org），并对其促使老年人参与ACP的效果进行了试点测试。
在基线时以及查看PREPARE网站1周后，我们使用一份经过验证的调查问卷评估了ACP中的行为改变，该问卷包括过程指标（知识、沉思、自我效能感和准备度，采用5级李克特量表）和行动指标（是否完成了某项ACP行为，是/否）。我们还将参与者分为行为改变阶段（即前沉思、沉思、准备、行动、维持），并确定了从基线时的前沉思阶段转变为1周后的更高阶段的参与者百分比。我们还评估了PREPARE的易用性（10分制，10分表示最容易）。使用威尔科克森符号秩和检验和麦克尼马尔检验评估变化情况。
参与者的平均年龄为68.4岁（标准差6.6），65%为非白人。行为改变过程指标的平均李克特得分从3.1（0.9）提高到3.7（0.7），P<0.001。行动指标没有显著变化。然而，大多数行动的前沉思阶段显著减少（例如，与医生谈论期望的医疗护理，从61%降至35%，P<0.003），平均减少21%（范围为16%-33%）。PREPARE的易用性评分为十分制中的九分（±1.9）。
一个以患者为中心的新的ACP网站，专注于让患者为沟通和决策做好准备，显著提高了对ACP过程和行为改变的参与度。目前正在对PREPARE进行一项临床试验。
