Sudore Rebecca L, Boscardin John, Feuz Mariko A, McMahan Ryan D, Katen Mary T, Barnes Deborah E
Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.
San Francisco Veterans Affairs Medical Center, San Francisco, San Francisco, California.
JAMA Intern Med. 2017 Aug 1;177(8):1102-1109. doi: 10.1001/jamainternmed.2017.1607.
Documentation rates of patients' medical wishes are often low. It is unknown whether easy-to-use, patient-facing advance care planning (ACP) interventions can overcome barriers to planning in busy primary care settings.
To compare the efficacy of an interactive, patient-centered ACP website (PREPARE) with an easy-to-read advance directive (AD) to increase planning documentation.
DESIGN, SETTING, AND PARTICIPANTS: This was a comparative effectiveness randomized clinical trial from April 2013 to July 2016 conducted at multiple primary care clinics at the San Francisco VA Medical Center. Inclusion criteria were age of a least 60 years; at least 2 chronic and/or serious conditions; and 2 or more primary care visits; and 2 or more additional clinic, hospital, or emergency room visits in the last year.
Participants were randomized to review PREPARE plus an easy-to-read AD or the AD alone. There were no clinician and/or system-level interventions or education. Research staff were blinded for all follow-up measurements.
The primary outcome was new ACP documentation (ie, legal forms and/or discussions) at 9 months. Secondary outcomes included patient-reported ACP engagement at 1 week, 3 months, and 6 months using validated surveys of behavior change process measures (ie, 5-point knowledge, self-efficacy, readiness scales) and action measures (eg, surrogate designation, using a 0-25 scale). We used intention-to-treat, mixed-effects logistic and linear regression, controlling for time, health literacy, race/ethnicity, baseline ACP, and clustering by physician.
The mean (SD) age of 414 participants was 71 (8) years, 38 (9%) were women, 83 (20%) had limited literacy, and 179 (43%) were nonwhite. No participant characteristic differed significantly among study arms at baseline. Retention at 6 months was 90%. Advance care planning documentation 6 months after enrollment was higher in the PREPARE arm vs the AD-alone arm (adjusted 35% vs 25%; odds ratio, 1.61 [95% CI, 1.03-2.51]; P = .04). PREPARE also resulted in higher self-reported ACP engagement at each follow-up, including higher process and action scores; P <.001 at each follow-up).
Easy-to-use, patient-facing ACP tools, without clinician- and/or system-level interventions, can increase planning documentation 25% to 35%. Combining the PREPARE website with an easy-to-read AD resulted in higher planning documentation than the AD alone, suggesting that PREPARE may increase planning documentation with minimal health care system resources.
clinicaltrials.gov Identifier: NCT01550731.
患者医疗意愿的记录率通常较低。尚不清楚易于使用的、面向患者的预先护理计划（ACP）干预措施能否克服繁忙的初级保健环境中进行计划的障碍。
比较交互式、以患者为中心的ACP网站（PREPARE）与易于阅读的预先指示（AD）在增加计划记录方面的效果。
设计、设置和参与者：这是一项2013年4月至2016年7月在旧金山退伍军人医疗中心的多个初级保健诊所进行的比较有效性随机临床试验。纳入标准为年龄至少60岁；至少患有2种慢性和/或严重疾病；进行过2次或更多次初级保健就诊；以及在过去一年中进行过2次或更多次额外的诊所、医院或急诊室就诊。
参与者被随机分为查看PREPARE加易于阅读的AD或仅查看AD。没有临床医生和/或系统层面的干预措施或教育。研究人员对所有随访测量进行盲法处理。
主要结局是9个月时新的ACP记录（即法律表格和/或讨论）。次要结局包括使用经过验证的行为改变过程测量（即5分制的知识、自我效能感、准备程度量表）和行动测量（例如代理人指定，使用0 - 25分制）的调查，在1周、3个月和6个月时患者报告的ACP参与情况。我们采用意向性分析、混合效应逻辑回归和线性回归，控制时间、健康素养、种族/民族、基线ACP以及医生聚类情况。
414名参与者的平均（标准差）年龄为71（8）岁，38名（9%）为女性，83名（20%）识字能力有限，179名（
