Center for Innovations in Quality Effectiveness, and Safety, Houston, Texas.
Michael E. DeBakey VA Medical Center, Houston, Texas.
J Am Geriatr Soc. 2020 Jun;68(6):1210-1217. doi: 10.1111/jgs.16405. Epub 2020 Mar 10.
BACKGROUND/OBJECTIVES: A patient-directed, online program (PREPARE for Your Care [PREPARE]; prepareforyourcare.org) has been shown to increase advance care planning (ACP) documentation. However, the mechanisms underlying PREPARE are unknown. Our objectives were to compare the efficacy of PREPARE plus an easy-to-read advance directive (AD) vs an AD alone to increase active patient participation in ACP discussions during clinic visits and to examine effects of active patient participation on ACP documentation.
Audio recordings of postintervention primary care visits from two randomized trials (2013-2016).
Seven primary care clinics at a veterans affair and safety-net hospital in San Francisco, CA.
English- and Spanish-speaking adults, aged 55 years and older, with two or more chronic/serious conditions.
PREPARE plus an easy-to-read AD or an AD alone.
The primary outcome was the number of active patient participation utterances about ACP (eg, asking questions, stating preferences) measured by the validated Active Patient Participation Coding Scheme. We examined differences in utterances by study arm using mixed effects negative binomial models and utterances as a mediator of PREPARE's effect on documentation using adjusted logistic regression. Models were adjusted for health literacy, prior care planning, and clinician.
Among 393 participants, the mean (SD) age was 66 (8.1) years, 120 (30.5%) had limited health literacy, and 99 (25.2%) were Spanish speaking. PREPARE plus the AD resulted in 41% more active patient participation in ACP discussions compared with the AD alone (mean [SD] = 10.1 [16.8] vs 6.6 [13.4] utterances; incidence rate ratio = 1.41; 95% confidence interval = 1.00-1.98). For every additional utterance, participants had 15% higher odds of ACP documentation, and active patient participation accounted for 16% of PREPARE's effect on documentation.
The PREPARE program and easy-to-read AD empowered patients to actively participate in ACP discussions during clinical visits more than the AD alone. Increased activation was associated with increased ACP documentation. Therefore, PREPARE may mitigate barriers to ACP among English- and Spanish-speaking older adults.
ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941. J Am Geriatr Soc 68:1210-1217, 2020.
背景/目的：一项以患者为导向的在线项目（准备您的护理[PREPARE]；prepareforyourcare.org）已被证明可以增加预先护理计划（ACP）的文档记录。然而，PREPARE 的机制尚不清楚。我们的目标是比较 PREPARE 加易于阅读的预嘱（AD）与单独使用 AD 来增加积极参与 ACP 讨论的患者比例，并研究积极参与 ACP 对 ACP 文档记录的影响。
来自两项随机试验（2013-2016 年）的干预后初级保健就诊的音频记录。
加利福尼亚州旧金山退伍军人事务和保障网医院的七个初级保健诊所。
年龄在 55 岁及以上、有两种或两种以上慢性/严重疾病、能说英语和西班牙语的成年人。
PREPARE 加易于阅读的 AD 或单独的 AD。
主要结果是通过经过验证的积极参与患者编码方案衡量的关于 ACP 的积极参与患者发言的数量（例如，提出问题、表达偏好）。我们使用混合效应负二项式模型检查了不同研究臂之间的话语差异，并使用调整后的逻辑回归检查了话语作为 PREPARE 对文档记录影响的中介。模型根据健康素养、预先护理计划和临床医生进行了调整。
在 393 名参与者中，平均（SD）年龄为 66（8.1）岁，120 名（30.5%）健康素养有限，99 名（25.2%）为西班牙语使用者。与单独使用 AD 相比，PREPARE 加 AD 使 ACP 讨论中的积极参与增加了 41%（平均[SD]=10.1[16.8]与 6.6[13.4]次发言；发病率比=1.41；95%置信区间=1.00-1.98）。每增加一次发言，参与者进行 ACP 文档记录的几率就会增加 15%，而积极参与占 PREPARE 对文档记录影响的 16%。
PREPARE 计划和易于阅读的 AD 使患者在临床就诊时更积极地参与 ACP 讨论，而不仅仅是 AD 本身。更多的激活与增加 ACP 文档记录有关。因此，PREPARE 可能会减轻英语和西班牙语老年人进行 ACP 的障碍。
ClinicalTrials.gov 标识符：“通过为多样化的老年人做好决策准备来改善预先护理计划（PREPARE）”NCT01990235 和“为西班牙语裔老年人做好预先护理计划和医疗决策准备（PREPARE）”NCT02072941。J Am Geriatr Soc 68:1210-1217, 2020.
