Missed Opportunities and Health Disparities for Advance Care Planning Before Elective Surgery in Older Adults

Abstract

ImportanceAdvance care planning (ACP) prepares patients and caregivers for medical decision-making, yet it is underused in the perioperative surgical setting, particularly among older adults undergoing high-risk procedures who are at risk for postoperative complications. It is unknown what patient factors are associated with perioperative ACP documentation among older surgical patients.ObjectiveTo assess ACP documentation among high-risk patients 65 years and older undergoing elective surgery.Design, Setting, and ParticipantsIn this observational cohort study including 3671 patients 65 years and older undergoing elective surgery at a tertiary academic center in California, electronic health record data were linked to the National Surgical Quality Improvement Project outcomes data and the California statewide death registry. The study was conducted from January 1 to December 31, 2019. Data were analyzed from January to May 2022.ExposuresElective surgery requiring an inpatient admission.Main Outcomes and MeasuresACP documentation, defined as a discussion regarding goals of care documented in an ACP note, an advance directive, or a physician order for life-sustaining treatment (POLST) form, within 90 days before elective surgery requiring inpatient admission. Multivariate regression was performed to identify factors associated with missing ACP.ResultsAmong 3671 patients (median [IQR] age 72 [65-94] years; 1784 [48.6%] female; 401 [10.9%] Asian, 155 [4.2%] Black, 284 [7.7%] Latino/Latina, 2647 [72.1%] White, and 184 [5.0%] of other races or ethnicities, including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, other, and unknown or declined to respond, combined owing to small numbers), 539 (14.7%) had ACP documentation in the 90-day presurgery window. Of these 539, 448 (83.1%) had advance directives, and 60 (11.1%) had POLST forms. The 30-day and 1-year mortality were 0.7% (n = 27) and 6.6% (n = 244), respectively. Missing ACP was significantly associated with male sex (adjusted odds ratio [aOR], 1.39; 95% CI, 1.14-1.69) and having a non-English preferred language (aOR, 1.78; 95% CI, 1.18-2.79). Medicare insurance was significantly associated with having ACP (aOR for missing ACP, 0.63; 95% CI, 0.40-0.95).Conclusions and RelevanceIn this study, perioperative ACP was uncommon, particularly in men, individuals with a non-English preferred language, and those without Medicare insurance coverage. The perioperative setting may represent a missed opportunity for ACP for older surgical patients. When addressing ACP for surgical patients, particular attention should be paid to overcoming language-related disparities.

Quality Improvement Initiative Implementation at the Unit or Hospital Level

“…Participation led to an examination of our own performance on the metric and demonstrated that less than 15% of older adult patients undergoing major elective surgery had ACP documentation in the metric-defined 90-day presurgery window . 7 Furthermore, these data showed disparities in rates of ACP, with it being particularly uncommon in men and individuals who prefer a non-English language.…”

Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement

“…Similar to prior work among elective surgical patients, we show that patients with higher odds of having ACP documentation tended to be older, prefer English, and possess government-funded health insurance. 14,19 While Medicare insurance may be a proxy for older age, which was also predictive of ACP documentation, funding structures such as reimbursement for ACP conducted during annual wellness visits, which began in 2016 have also been associated with an overall increase in ACP. 20 Importantly, however, as part of this reimbursement structure, only ACP conversations conducted as part of an annual wellness visit are protected from additional out-of-pocket patient costs.…”

“…Furthermore, Black, Hispanic, and Medicaid dual-eligible patients and patients with comorbidities are less likely to have annual wellness visits and also less likely to have ACP billed as part of one of these visits. Non-English preferred language is known to be a significant barrier to ACP among surgical patients, 14 and several factors likely contribute to these differences, including cultural norms and patient preferences, yet lack of access to high-quality language-concordant ACP continues to be demonstrated across clinical contexts 21 . For example, among 18,490 seriously ill older adults, patients with non-English preferred language had higher end-of life health care utilization (higher odds of emergency department visits, readmission, in-hospital death) but were less likely to have ACP documents 22 .…”

“…For race and ethnicity, we used derived variables developed by our institution in which patients self-select one or more race/ethnicity categories. Race and ethnicity were included because prior data from surgical and nonsurgical populations have shown differing ACP documentation rates among minoritized populations, 14 and we wanted to understand if such disparities exist among EGS patients specifically. To evaluate association between social determinants of health and ACP completion, the Neighborhood Deprivation Index was linked by ZIP code.…”

A Sobering Tale of Missed Opportunities for Advance Care Planning—Now Is the Time for Action

“…Colley et al report sobering data that highlight a series of missed opportunities for advance care planning (ACP). Despite allowing ACP documentation within a generous 90-day preoperative window, the authors found that less than 15% of older patients (age ≥65 years) undergoing inpatient elective surgery had ACP documentation, and only 19.5% of patients who were admitted to the intensive care unit had this documentation.…”