Abstract
This cohort study evaluates the addition of a patient-centered intervention to an advance care planning process for older surgical patients.
Introduction
Advancements in perioperative care have made immediate catastrophic complications of major elective operations rare, yet the need for surgical intervention may signal declining health for older adults. Therefore, the period before a major operation may be an opportune time for advance care planning (ACP).1 Barriers to the widespread adoption of ACP in surgery remain.2 We evaluated the integration of a patient-centered tool (PREPARE) into an electronic health record (EHR) patient-portal message sent to patients before surgical consultation.3 This integration was intended to allow patients to self-engage with ACP while removing dependency on the surgical team for ACP initiation.
Methods
This retrospective cohort study was conducted at a tertiary academic cancer center using EHR data. The University of California, San Francisco Institutional Review Board deemed this study exempt from review and waived the informed consent requirement because it was not human participant research. We followed the STROBE reporting guideline.
We included patients in 4 surgical clinics (colorectal, hepatobiliary, endocrine, thoracic) who were 65 years or older and scheduled for a new patient visit (June 1, 2022, to June 1, 2023). One week before the visit, patients received an EHR message explaining ACP with a hyperlink to PREPARE (available in English and Spanish). The message was written in English or Spanish, based on the patient’s self-identified preferred language in the EHR. Two multilingual and ACP-trained health care nonclinical navigators (HCNs) conducted follow-up telephone calls, targeting patients with high comorbidity.
Primary outcome was a newly updated advance directive (AD) within 90 days of the message. Secondary outcomes were a composite of clinically meaningful ACP (ACP billing codes, ACP notes, scanned ACP documentation [ADs, Physician Orders for Life-Sustaining Treatment forms]). Descriptive statistics were performed using available covariates. Analysis was conducted with SAS 9.4 (SAS Institute Inc); P < .05 indicated statistical significance.
Results
A total of 2550 new surgical patients (1418 females [55.6%], 1129 males [44.3%]; mean [SD] age, 71 [9.0] years) received the EHR message, among whom 499 (24.3%) were also contacted by an HCN (Table 1). Compared with the message-only group, the message-plus-HCN group was more likely to have newly uploaded ADs (47 [9.4%] vs 74 [3.6%]; P < .001) and visit colorectal surgical clinics (130 [26.1%] vs 433 [21.1%]; P < .001). In 1 year, clinically meaningful ACP was documented in the EHR more often in the message-plus-HCN group vs message-only group (364 [72.9%] vs 311 [15.2%]; P < .001) (Table 2).
Table 1. Frequency of Newly Uploaded AD.
| Variable | No. (%) | P value | |
|---|---|---|---|
| Newly uploaded AD | No newly uploaded AD | ||
| Age, mean (SD), y | 71.5 (7.8) | 71.0 (9.0) | .54 |
| Gender identity | |||
| Female | 76 (62.8) | 1342 (55.3) | .25 |
| Male | 45 (37.2) | 1084 (44.6) | |
| Unknown | 0 | 3 (0.1) | |
| Preferred language | |||
| Chinese | 0 | 71 (2.9) | .27 |
| English | 118 (97.5) | 2170 (89.3) | |
| Spanish | 0 | 60 (2.5) | |
| Othera | 3 (2.5) | 129 (5.3) | |
| Marital status | |||
| Partneredb | 73 (60.3) | 1569 (64.6) | .61 |
| Singleb | 29 (24.0) | 551 (22.7) | |
| Unknown or declined to answer | 3 (2.5) | 71 (2.9) | |
| Widowed | 16 (13.2) | 239 (9.8) | |
| Charlson Comorbidity Index | |||
| 0-3 | 71 (58.7) | 1228 (50.5) | .08 |
| >4 | 50 (41.3) | 1202 (49.5) | |
| Insurance type | |||
| Commercial | 17 (14.0) | 332 (13.7) | .86 |
| Medi-Cal | 5 (4.1) | 155 (6.4) | |
| Medicare | 97 (80.2) | 1900 (78.2) | |
| None | 1 (0.8) | 30 (1.2) | |
| Otherc | 1 (0.8) | 13 (0.5) | |
| UCSF primary care | 8 (6.5) | 232 (9.5) | .28 |
| UCSF palliative care | 1 (0.8) | 57 (2.3) | .27 |
| Surgical clinic | |||
| Colorectal | 21 (17.4) | 542 (22.3) | .19 |
| Endocrine | 27 (22.3) | 504 (20.7) | |
| Hepatobiliary | 46 (38.0) | 1021 (42.0) | |
| Thoracic | 27 (22.3) | 362 (14.9) | |
Abbreviations: AD, advance directive; UCSF, University of California San Francisco.
Other languages include Arabic, Burmese, Cambodian, Dari, Farsi, Gujarati, Hindi, Japanese, Khmer, Korean, Laotian, Mon-Khmer, Persian, Portuguese, Punjabi, Romanian, Russian, Tagalog, Thai, Tigrinya, Turkish, and Vietnamese.
Partnered is defined as being married, having a significant other, or having a registered domestic partner. Single is defined as single, divorced, or legally separated.
Other insurance include capitation plans.
Table 2. Frequency of Clinically Meaningful Advance Care Planning Between the Message Only Group and Message Plus Navigator Group.
| Outcome | No. (%) | |
|---|---|---|
| Message only group (n = 2051) | Message + HCN group (n = 499) | |
| Primary outcome | ||
| Newly uploaded AD | 74 (3.6) | 47 (9.4) |
| Secondary outcomes | ||
| New ACP CPT code | 7 (0.3) | 4 (0.8) |
| New ACP Notes | 25 (1.2) | 3 (0.6) |
| New ACP SmartLink | 243 (11.8) | 360 (72.1) |
| New scanned ACP documentation (AD, POLST forms) | 90 (4.4) | 51 (10.2) |
| Total new clinically meaningful ACP | 311 (15.2) | 364 (72.9) |
Abbreviations: ACP, advance care planning; AD, advance directive; CPT, Current Procedural Terminology; HCN, health care nonclinical navigator; POLST, Physician Orders For Life-Sustaining Treatment.
Discussion
Findings suggest that HCN support was associated with enhanced AD completion vs ACP messages alone. Routine messaging with HCN follow-up could increase ACP engagement without overburdening surgical practices.3,4
Study limitations include the short follow-up, which may not capture patients initiating but not completing an AD within 90 days. However, for this and other reasons (eg, patients engaging informally in ACP), the intervention likely had greater benefits than can be captured in the EHR. Additionally, given AD’s complex legal nature, both HCNs and patients encountered challenges in uploading documentation in the EHR. Efforts to simplify the legal execution and EHR upload for ADs may facilitate further availability in the EHR.
For older adults seeking consultation for major elective surgery, addition of HCN outreach to a standardized EHR message about ACP was associated with more ADs and ACP-related documentation. System-level resources are needed to simplify the documentation upload workflow.
Data Sharing Statement
References
- 1.Colley A, Lin JA, Pierce L, Finlayson E, Sudore RL, Wick E. Missed opportunities and health disparities for advance care planning before elective surgery in older adults. JAMA Surg. 2022;157(10):e223687. doi: 10.1001/jamasurg.2022.3687 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Tang VL, Dillon EC, Yang Y, et al. Advance care planning in older adults with multiple chronic conditions undergoing high-risk surgery. JAMA Surg. 2019;154(3):261-264. doi: 10.1001/jamasurg.2018.4647 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Sudore RL, Boscardin J, Feuz MA, McMahan RD, Katen MT, Barnes DE. 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. JAMA Intern Med. 2017;177(8):1102-1109. doi: 10.1001/jamainternmed.2017.1607 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Kubi B, Istl AC, Lee KT, Conca-Cheng A, Johnston FM. Advance care planning in cancer: patient preferences for personnel and timing. JCO Oncol Pract. 2020;16(9):e875-e883. doi: 10.1200/JOP.19.00367 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Sharing Statement