Ferguson Clarissa M, Gilissen Joni, Scheerens Charlotte, Volow Aiesha, Powell Jana, Shi Ying, McMahan Ryan, Barnes Deborah, Sudore Rebecca L
Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.
Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
J Am Geriatr Soc. 2024 Dec;72(12):3833-3839. doi: 10.1111/jgs.19127. Epub 2024 Aug 9.
Advance care planning (ACP) has been reconceptualized as a health behavior. Action plans (APs), or patient-directed mini contracts, improve behavior change. However, no prior studies have assessed whether APs can increase ACP documentation and engagement.
We included English and Spanish-speaking primary care patients from San Francisco, ≥55 years of age, with ≥2 serious or chronic illnesses. Participants were in the intervention arm of the PREPAREforYOURcare.org trial and asked at baseline to choose 1 of 5 actions (e.g., choose a surrogate). At 6 months, we assessed whether participants completed their AP and if completion was associated with demographics, electronic health record (EHR) ACP documentation, and five-point ACP Engagement Survey scores. We used t-tests, chi-squared, multivariate analysis adjusted for baseline ACP and clustering by physician, and qualitative thematic analysis to explore reasons for non-completion.
The mean age of 586 participants was 65 ± 10 years; 44.0% women, 45.9% Spanish-speaking, 31.4% had limited health literacy, and 43% completed an AP at 6 months; surrogate-related (47.4%), tell others about medical wishes (33.7%), ask clinicians questions (13.7%), and decide what matters most in life (5.2%). Participants with limited versus adequate health literacy were less likely to complete an AP (25.4% vs 35.9%, p = 0.01). Completing an AP was associated with greater ACP EMR documentation 49.8% vs 35.6%, p < 0.001 (adjusted odds ratio: 2.06; 95% CI [1.43-2.97]) and engagement (adjusted five-point scores [3.69; 95% CI 3.57-3.81 vs 3.10; 95% CI: 2.98-3.21], p < 0.001). Themes for non-completion included not being ready and logistical issues (e.g., surrogate deceased).
Among English and Spanish-speaking older adults, creating an ACP AP resulted in greater documentation and engagement. APs may help facilitate ACP behavior change as part of effective ACP interventions. Additional support may be needed for patients with limited health literacy and those facing logistical barriers.
预先护理计划（ACP）已被重新定义为一种健康行为。行动计划（AP），即患者主导的小型契约，可促进行为改变。然而，此前尚无研究评估AP是否能增加ACP文件记录及参与度。
我们纳入了来自旧金山年龄≥55岁、患有≥2种严重或慢性疾病、说英语和西班牙语的初级保健患者。参与者处于PREPAREforYOURcare.org试验的干预组，在基线时被要求从5种行动中选择1种（例如，选择一名替代决策者）。在6个月时，我们评估参与者是否完成了他们的AP，以及完成情况是否与人口统计学特征、电子健康记录（EHR）中的ACP文件记录和五点式ACP参与度调查得分相关。我们使用t检验、卡方检验、针对基线ACP进行调整并按医生进行聚类的多变量分析，以及定性主题分析来探究未完成的原因。
586名参与者的平均年龄为65±10岁；44.0%为女性，45.9%说西班牙语，31.4%健康素养有限，43%在6个月时完成了AP；与替代决策者相关的行动（47.4%）、告知他人医疗意愿（33.7%）、向临床医生提问（13.7%）以及确定生活中最重要的事情（5.2%）。健康素养有限与健康素养足够的参与者完成AP的可能性较低（25.4%对35.9%，p = 0.01）。完成AP与更多的ACP电子病历文件记录相关（49.8%对35.6%，p < 0.001，调整后的优势比：2.06；95%置信区间[1.43 - 2.97]）以及更高的参与度（调整后的五点得分[3.69；95%置信区间3.57 - 3.81对3.10；95%置信区间：2.98 - 3.21]，p < 0.001）。未完成的主题包括尚未准备好和后勤问题（例如，替代决策者去世）。
在说英语和西班牙语的老年人中，制定ACP AP可带来更多的文件记录和参与度。作为有效的ACP干预措施的一部分，AP可能有助于促进ACP行为改变。对于健康素养有限的患者以及面临后勤障碍的患者，可能需要额外的支持。
