Effect of the PREPARE Website vs an Easy-to-Read Advance Directive on Advance Care Planning Documentation and Engagement Among Veterans

Sudore, Rebecca L.; Boscardin, John; Feuz, Mariko; McMahan, Ryan D.; Katen, Mary; Barnes, Deborah E.

doi:10.1001/jamainternmed.2017.1607

Cited by 195 publications

(274 citation statements)

References 38 publications

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“…The VA is an exceptional national model of ACP documentation in that it includes a centralized posting section in the EHR for ACP, is dedicated to ACP initiatives, 13–17,25,29 and half of chronically ill, older Veterans in this study had documented ACP wishes, well above national norms. 30 However, given that many non-VA health systems do not have similar established EHRs and dedicated ACP programs, these study findings point to a likely widely generalizable quality improvement gap for patient safety in ACP.…”

Section: Discussionmentioning

confidence: 83%

Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

Walker

McMahan²,

Barnes

et al. 2018

Journal of Pain and Symptom Management

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Importance Documenting patients’ advance care planning wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about advance care planning documentation practices in the electronic health record. Objective Describe advance care planning documentation practices and the accessibility of documented discussions in the electronic health record. Design Cross-sectional study between 2013-2015. Setting Primary care clinics at the San Francisco Veterans Affairs Medical Center. Participants Veterans ≥60 years of age with ≥2 chronic/serious health conditions, ≥2 primary care visits, and ≥2 additional clinic/hospital/emergency room visits in the prior year who were participating in an advance care planning trial. Exposure Documentation of advance care planning in the electronic health record. Main Measures Advance care planning documentation, including all prior legal forms/orders and documented discussions within the prior five years. For discussions, the author’s discipline and documentation location in the electronic health record were determined. Discussions were defined as “accessible” if documented in a designated electronic posting location or “not easily accessible” if recorded as free-text in progress notes. Percentages and means were used to describe these measures. Key Results The mean age of 414 participants was 71 years (SD ±8), 9% were women, 43% were non-white, and 51% had documented advance care planning including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders did not have accompanying documented discussions. Most (55%) discussions were not easily accessible. Twenty-seven participants had a subsequent discussion documenting changes in treatment preferences from a prior form/order; however, 70% of these discussions were not easily accessible. Conclusions and Relevance Half of chronically ill, older participants had documented advance care planning wishes, including one third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying explanatory discussions. The majority of documented discussions were not easily accessible in the electronic health record, including 70% of those documenting a change in treatment preferences. Ensuring that patients’ preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients’ wishes are honored.

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Section: Discussionmentioning

confidence: 83%

Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

Walker

McMahan²,

Barnes

et al. 2018

Journal of Pain and Symptom Management

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“…In addition, the baseline ACP documentation rate in the 12-months prior to enrollment was determined using a composite of legal forms or documented ACP discussions. 20,21 …”

Section: Methodsmentioning

confidence: 99%

Engaging Diverse English- and Spanish-Speaking Older Adults in Advance Care Planning

et al. 2018

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IMPORTANCE: Advance care planning improves the receipt of medical care aligned with patients’ values; yet, it remains sub-optimal among diverse patient populations. To mitigate literacy, cultural, and language barriers to advance care planning, we created easy-to-read advance directives and a patient-directed, online advance care planning program called PREPARE in English and Spanish. OBJECTIVE: To compare the efficacy of PREPARE plus an easy-to-read advance directive to an advance directive alone to increase advance care planning documentation and patient-reported engagement. DESIGN: Comparative efficacy randomized trial from February 2014 to November 2017. SETTING: Four San Francisco, safety-net, primary-care clinics. PARTICIPANTS: English- or Spanish-speaking primary care patients, age ≥55 years, with ≥2 chronic or serious illnesses. INTERVENTIONS: Participants were randomized to PREPARE plus an easy-to-read advance directive (PREPARE) or the advance directive alone. There were no clinician/system-level interventions. Staff were blinded for all follow-up measurements. MAIN OUTCOMES AND MEASURES: The primary outcome was new advance care planning documentation (i.e., legal forms and/or documented discussions) at 15 months. Patient-reported outcomes included advance care planning engagement at baseline, 1 week, and 3, 6, and 12-months using validated surveys. We used intention-to-treat, mixed-effects logistic and linear regression, controlling for time, health literacy and baseline advance care planning, clustering by physician, and stratifying by language. RESULTS: The mean (SD) age of 986 participants was 63.3 years (± 6.4), 39.7% had limited health literacy, and 45% were Spanish-speaking. No participant characteristic differed between arms; retention was 85.9%. Compared to the advance directive alone, PREPARE resulted in higher advance care planning documentation (adjusted 43% vs. 32%; p<0.001) and higher self-reported increased advance care planning engagement scores (98.1% vs. 89.5%; p<0.001). Results remained significant among English and Spanish-speakers. CONCLUSIONS AND RELEVANCE: The patient-facing PREPARE program and an easy-to-read advance directive, without clinician/system-level interventions, increased advance care planning documentation and patient-reported engagement, with statistically higher gains for PREPARE. These tools may mitigate literacy and language barriers to advance care planning, allow patients to begin planning on their own, and could substantially improve the process for diverse, English- and Spanish-speaking populations.

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“…This is a cross‐sectional study of baseline data collected from 2013 to 2017 from two randomized controlled trials evaluating the efficacy of http://prepareforyourcare.org, a video‐based, interactive ACP website vs easy‐to‐read advance directives. The trial results and the methods have been previously published . These studies were approved by the Institutional Review Boards of the University of California, San Francisco.…”

Section: Methodsmentioning

confidence: 99%

“…The trial results and the methods have been previously published. 15,16 These studies were approved by the Institutional Review Boards of the University of California, San Francisco. Written informed consent was obtained for all participants.…”

Section: Methodsmentioning

confidence: 99%

Health Literacy Matters More Than Experience for Advance Care Planning Knowledge Among Older Adults

Nouri

Barnes

Volow

et al. 2019

J American Geriatrics Society

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BACKGROUND Advance care planning (ACP) engagement is low among vulnerable populations, including those with limited health literacy (LHL). Limited knowledge about ACP may be a modifiable mediator of the relationship between LHL and ACP. Our goal was to determine whether health literacy is associated with ACP knowledge. DESIGN Cross‐sectional design. SETTING A public health delivery system and Veterans Affairs Medical Center in San Francisco, CA. PARTICIPANTS English‐ and Spanish‐speaking patients (N = 1400). MEASUREMENTS ACP knowledge was assessed with seven validated multiple‐choice questions. Health literacy was measured using a validated scale. Sociodemographic measures included age, sex, language, education, race, health status, and social support. Prior ACP experience was defined as having documented legal forms and/or goals‐of‐care discussions in the medical record. We used Kruskal‐Wallis tests and linear regression to examine associations of ACP knowledge with LHL, prior ACP experience, and sociodemographic factors. RESULTS Mean age of participants was 65 (±10) years, 48% were women, 34% had LHL, 32% were Spanish speaking, 47% had high school education or less, and 70% were nonwhite. Mean 7‐point knowledge scores were lower for those with limited vs adequate health literacy (3.8 [SD = 1.9 vs 5.5 (SD = 1.7); P < .001). In multivariable analysis, ACP knowledge scores were 1.0 point lower among those with LHL; 0.6 points lower among Spanish speakers and those with high school education or less; and 0.5 points lower among individuals of nonwhite race (P < .001 for all). Knowledge scores were 0.02 points lower per year of older age (P = .007) and 0.01 points higher per point of greater social support (P = .005). Prior ACP experience was not associated with knowledge after adjustment (P = .7). CONCLUSIONS Health literacy and sociodemographics are stronger predictors than prior ACP experience of ACP knowledge. This study suggests that providing easy‐to‐understand ACP materials is paramount and should be offered even if patients have previous experience with the ACP process. J Am Geriatr Soc 67:2151–2156, 2019

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Effect of the PREPARE Website vs an Easy-to-Read Advance Directive on Advance Care Planning Documentation and Engagement Among Veterans

Cited by 195 publications

References 38 publications

Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

Engaging Diverse English- and Spanish-Speaking Older Adults in Advance Care Planning

Health Literacy Matters More Than Experience for Advance Care Planning Knowledge Among Older Adults

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