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Population-Based Pragmatic Trial Of Advance Care Planning In Primary Care In The University Of California Health System.

Anne M. Walling, Rebecca L Sudore, Doug Bell, Chi-Hong Tseng, Christine Seel Ritchie, Ron D. Hays, Lisa M. Gibbs, Maryam Rahimi, Javier Sanz, Neil S Wenger
Published 2019 · Medicine
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Introduction: Varying intensity of advance care planning (ACP) interventions at the population level has not been compared among seriously ill patients in primary care. This project will implement, test, and disseminate real-world scalable ACP interventions among primary care clinics across three University of California Health systems. The three ACP interventions are (1) distribution of an advance directive (AD) with targeted ACP messaging, (2) the AD, messaging, plus prompting patients to engage with the Prepare For Your Care website (PREPARE), and (3) the AD, messaging, PREPARE, plus Care Coordinator engagement with patients and clinicians. Methods: We will identify a population cohort of seriously ill primary care patients and implement the ACP interventions using electronic health record (EHR) patient portals and postal mailings. Forty-five clinics across the three health systems will be cluster randomized to one of the three ACP interventions. The primary outcome for the population cohort is AD or Physician Orders for Life-Sustaining Treatment documentation in the EHR. A subset of the population cohort will be surveyed to assess patient-centered outcomes, including care consistent with goals at baseline, 12 months, and 24 months. Caregivers will be interviewed if patients are unable to be surveyed or die. ACP documentation, goal concordant care, and among decedents, health care utilization will be compared among intervention arms. Study Implementation: Challenges and Contributions: The project is guided by a Study Advisory Group and Community Advisory Groups at each site to ensure rigorous patient-centered methods and consistency of implementation. Intervention fidelity will be evaluated using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Challenges to implementation of this three-site health system trial and to intervention fidelity stem from site/clinic/system cultures, increasing attention to end-of-life care from payers and regulators, and growing pressures by health systems to implement ACP interventions. Stakeholder engagement is required to ensure consistent interventions across sites.
This paper references
10.1111/j.1532-5415.2008.02093.x
A clinical framework for improving the advance care planning process: start with patients' self-identified barriers.
Adam D Schickedanz (2009)
10.1016/j.jpainsymman.2016.10.367
Measuring Advance Care Planning: Optimizing the Advance Care Planning Engagement Survey.
Rebecca L Sudore (2017)
10.1016/j.jamda.2014.01.008
Efficacy of advance care planning: a systematic review and meta-analysis.
Carmen H M Houben (2014)
10.1177/0272989X03256005
Validation of a Decision Regret Scale
Jamie C Brehaut (2003)
10.1016/j.jpainsymman.2015.07.018
"Doctor, Make My Decisions": Decision Control Preferences, Advance Care Planning, and Satisfaction With Communication Among Diverse Older Adults.
Catherine Chiu (2016)
10.1016/j.jpainsymman.2016.12.331
Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel.
Rebecca L Sudore (2017)
10.1371/journal.pone.0150671
Communication Tools for End-of-Life Decision-Making in Ambulatory Care Settings: A Systematic Review and Meta-Analysis
Simon J W Oczkowski (2016)
10.1046/j.1532-5415.2002.50116.x
Medical care inconsistent with patients' treatment goals: association with 1-year Medicare resource use and survival.
Joan M. Teno (2002)
10.7326/0003-4819-148-2-200801150-00010
Evidence for Improving Palliative Care at the End of Life A Systematic Review
Karl A. Lorenz (2008)
10.1371/journal.pone.0072465
Development and Validation of a Questionnaire to Detect Behavior Change in Multiple Advance Care Planning Behaviors
Rebecca L Sudore (2013)
10.1001/jamainternmed.2014.1183
Stability of end-of-life preferences: a systematic review of the evidence.
Catherine L. Auriemma (2014)
10.1111/j.1532-5415.2000.tb03140.x
Physician understanding of patient resuscitation preferences: insights and clinical implications.
Neil S Wenger (2000)
10.1001/jama.300.14.1665
Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.
Alexi A. Wright (2008)
10.1007/BF00451725
Development of the Kidney Disease Quality of Life (KDQOLTM) Instrument
Ron D. Hays (2004)
10.1001/jamainternmed.2017.1607
Effect of the PREPARE Website vs an Easy-to-Read Advance Directive on Advance Care Planning Documentation and Engagement Among Veterans: A Randomized Clinical Trial
Rebecca L Sudore (2017)
10.1007/s11136-009-9496-9
Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items
Ron D. Hays (2009)
10.1186/s41687-017-0003-8
Two-item PROMIS® global physical and mental health scales
Ron D. Hays (2017)
10.1007/BF02743161
Use of a modified informed consent process among vulnerable patients: a descriptive study
RL Sudore (2007)
10.1007/s10488-010-0319-7
Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda
Enola K Proctor (2010)
10.1016/j.pec.2007.08.015
An advance directive redesigned to meet the literacy level of most adults: a randomized trial.
Rebecca L Sudore (2007)
10.1080/07481187.2010.496686
Predictors of Complicated Grief: A Systematic Review of Empirical Studies
Elizabeth A Lobb (2010)
10.1007/s40271-013-0016-1
Evaluating the Content of the Communication Items in the CAHPS® Clinician and Group Survey and Supplemental Items with What High-Performing Physicians Say They Do
Denise D Quigley (2013)
10.2105/AJPH.89.9.1322
Evaluating the public health impact of health promotion interventions: the RE-AIM framework.
Russell E. Glasgow (1999)
10.1001/jamainternmed.2018.4657
Engaging Diverse English- and Spanish-Speaking Older Adults in Advance Care Planning: The PREPARE Randomized Clinical Trial
Rebecca L Sudore (2018)
10.1177/0269216314526272
The effects of advance care planning on end-of-life care: A systematic review
Arianne Brinkman-Stoppelenburg (2014)
10.1001/jama.1994.03520230049037
The Impact of Serious Illness on Patients' Families
Kenneth E. Covinsky (1994)
10.1089/jpm.2019.0346
Establishing a Denominator for Palliative Care Quality Metrics for Patients with Advanced Cancer.
S S Anand (2020)
10.1111/j.1532-5415.2005.53116.x
The effect of a social work intervention to enhance advance care planning documentation in the nursing home.
Rolfe Sean Morrison (2005)
Improving health care and palliative care for advanced and serious illness: closing the quality gap - revisiting the state of the science
Sydney Morss Dy (2012)
10.1200/JCO.2017.35.31_suppl.76
Implementing the Bereaved Family Survey for an advanced cancer population.
Jessica Kaltman (2017)
10.1089/jpm.2019.0117
Protocol for a Cluster Randomized Trial Comparing Team-Based to Clinician-Focused Implementation of Advance Care Planning in Primary Care.
Annette M. Totten (2019)
10.7326/0003-4819-153-4-201008170-00008
Redefining the “Planning” in Advance Care Planning: Preparing for End-of-Life Decision Making
Rebecca L Sudore (2010)
10.1089/jpm.2015.0039
Is Care for the Dying Improving in the United States?
Joan M. Teno (2015)
10.1089/jpm.2005.8.774
Religiousness and spirituality among HIV-infected Americans.
Karl A. Lorenz (2005)
10.1089/JPM.2013.0047
Respecting Choices® and advance directives in a diverse community.
E PecanacKristen (2014)



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