Eastern Colorado VA Geriatric Research Education and Clinical Center, Denver, Colorado, USA; Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, Colorado, USA.
San Francisco Veterans Affairs Health Care System, San Francisco, California, USA; Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA.
J Pain Symptom Manage. 2018 Oct;56(4):575-581.e7. doi: 10.1016/j.jpainsymman.2018.06.007. Epub 2018 Jun 27.
Advance care planning (ACP) engagement includes a wide range of behaviors and actions related to discussions and documentation, yet few ACP intervention studies measure the full process.
The objective of the study was to compare the effects of an easy-to-read advance directive (AD) versus an ACP web site plus the AD (PREPARE + AD) on Behavior Change Processes and Actions, including discussions and documentation.
Secondary data were from a completed ACP trial. Participants were primary care patients, ≥60 years old, with two comorbidities. We used the validated ACP Engagement Survey to examine six-month change in subscales measuring Behavior Change Processes (knowledge, contemplation, self-efficacy, readiness) and Actions (decision makers, quality of life, flexibility for decision makers, asking clinicians questions), specifically related to discussions and documentation. We used adjusted mixed-effects linear models to compare mean change and engagement over time.
Compared to the AD-only, PREPARE + AD resulted in greater increases in all Behavior Change Processes subscales and Actions related to decision makers, quality of life, and flexibility (all P-values ≤0.005). Both interventions significantly increased the proportion of participants who engaged in ACP discussions (PREPARE + AD, 99.5%; AD-only, 93.3%) and documentation (PREPARE + AD, 99.5%; AD-only, 90.4%), with greater increases for PREPARE + AD (all P-values <0.001).
Both PREPARE plus an easy-to-read AD and an AD-only markedly increased ACP engagement in a full range of ACP behaviors, including discussions and documentation, and engagement was nearly 100% with PREPARE + AD. Future ACP studies should examine a full range of ACP behaviors beyond ADs and the impact of PREPARE and easy-to-read AD implementation on health care systems.
预先医疗指示（ACP）的参与包括与讨论和文件记录相关的广泛行为和活动，但很少有 ACP 干预研究测量整个过程。
本研究的目的是比较易于阅读的预先医疗指示（AD）与 ACP 网站加 AD（PREPARE+AD）对行为改变过程和行为的影响，包括讨论和文件记录。
次要数据来自已完成的 ACP 试验。参与者为≥60 岁、有两种合并症的初级保健患者。我们使用经过验证的 ACP 参与调查来检查 6 个月时在衡量行为改变过程（知识、思考、自我效能、准备）和行为（决策者、生活质量、决策者的灵活性、向临床医生提问）的子量表上的变化，具体涉及讨论和文件记录。我们使用调整后的混合效应线性模型来比较随时间的平均变化和参与度。
与仅 AD 相比，PREPARE+AD 导致所有行为改变过程子量表以及与决策者、生活质量和灵活性相关的行为（所有 P 值≤0.005）的增加更大。两种干预措施都显著增加了参与 ACP 讨论（PREPARE+AD，99.5%；AD 仅，93.3%）和文件记录（PREPARE+AD，99.5%；AD 仅，90.4%）的参与者比例，PREPARE+AD 的增加更大（所有 P 值均<0.001）。
PREPARE 加易于阅读的 AD 和仅 AD 都显著增加了 ACP 的广泛行为参与度，包括讨论和文件记录，PREPARE+AD 的参与度几乎达到 100%。未来的 ACP 研究应检查除 AD 之外的 ACP 行为的全范围，并检查 PREPARE 和易于阅读的 AD 实施对医疗保健系统的影响。
