Key Points
Question
What are the effects of different behavioral health approaches on engagement in advance care planning?
Findings
In this randomized clinical trial of 483 veterans aged 55 years and older randomized to motivation interviewing (MI), motivational enhancement therapy (MET), computer-tailored print feedback, or usual care, significantly greater proportions of those randomized to MI (15.8%; 95% CI, 10.2%-23.6%) and MET (17.7%; 95% CI, 11.7%-25.8%) completed a full set of advance care planning activities compared with those receiving usual care (5.7%; 95% CI, 2.8%-11.1%).
Meaning
These findings suggest that MI and MET, approaches to behavior change involving brief clinical interactions focused on exploring and resolving ambivalence, are efficacious in increasing advance care planning engagement.
This randomized clinical trial examine the efficacy of computer-tailored print feedback (CTPF), motivational interviewing (MI), and motivational enhancement therapy (MET) on completion of a set of advance care planning activities, each as compared with usual care.
Abstract
Importance
There is a tension between clinician-led approaches to engagement in advance care planning (ACP), which are effective but resource-intensive, and self-administered tools, which are more easily disseminated but rely on ability and willingness to complete.
Objective
To examine the efficacy of computer-tailored print feedback (CTPF), motivational interviewing (MI), and motivational enhancement therapy (MET) on completion of a set of ACP activities, each as compared with usual care.
Design, Setting, and Participants
This randomized clinical trial was conducted from October 2017 to December 2020 via telephone contact with primary care patients at a single VA facility; 483 veterans aged 55 years or older were randomly selected from a list of patients with a primary care visit in the prior 12 months, with oversampling of women and people from minoritized racial and ethnic groups. Statistical analysis was performed from January to June 2022.
Interventions
Mailed CTPF generated in response to a brief telephone assessment of readiness to engage in and attitudes toward ACP; MI, an interview exploring ambivalence to change and developing a change plan; and MET, MI plus print feedback, delivered by telephone at baseline, 2, and 4 months.
Main Outcome and Measures
Self-reported completion of 4 ACP activities: communicating about views on quality vs quantity of life, assignment of a health care agent, completion of a living will, and submitting documents for inclusion in the electronic health record at 6 months.
Results
The study included 483 persons, mean (SD) age 68.3 (8.0) years, 18.2% women and 31.1% who were people from minoritized racial and ethnic groups. Adjusting for age, education, race, gender, and baseline stage of change for each ACP, predicted probabilities for completing the ACP activities were: usual care 5.7% (95% CI, 2.8%-11.1%) for usual care, 17.7% (95% CI, 11.8%-25.9%; P = .003) for MET, 15.8% (95% CI, 10.2%-23.6%; P = .01) for MI, P = .01, and 10.0% (95% CI, 5.9%-16.7%; P = .18) for CTPF.
Conclusions and Relevance
This randomized clinical trial found that a series of 3 MI and MET counseling sessions significantly increased the proportion of middle-aged and older veterans completing a set of ACP activities, while print feedback did not. These findings suggest the importance of clinical interaction for ACP engagement.
Trial Registration
ClinicalTrials.gov Identifier: NCT03103828
Introduction
Advance care planning (ACP), the process by which individuals and their potential surrogates can plan for decisional incapacity, is endorsed as a key component of high-quality illness care.1 The optimal form of advance care planning that can meaningfully improve patient and surrogate outcomes continues to be debated.2 The completion of instructional advance directives, such as living wills, focused on asking patients to prespecify the treatments they want to receive, cannot alone achieve these objectives. This form of ACP does not help the surrogate understand what is important to the patient, nor can it anticipate relevant considerations involved in complex end-of-life decisions or incorporate the guidance of clinicians.3 Instead, ACP has shifted its focus on helping patients and surrogates make the best possible in-the-moment decisions. A recent consensus definition of ACP is “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care.”4 According to this definition, ACP consists of communication between an individual, their loved ones, and their clinicians about goals and preferences; the assignment of a trusted other to serve as a surrogate decision maker; and written documentation of medical choices in a manner that can be found when needed.
This comprehensive definition of ACP requires patients and surrogates to engage in a multifaceted set of activities. The challenge is helping patients and surrogates to do this in a way that can be broadly implemented. More intensive facilitator-led interventions appear to have the largest effect on outcomes5,6 but also require the greatest resources.7 Tools designed for patients and their surrogates to use on their own have demonstrated efficacy and are more easily disseminated.8,9 However, they also depend upon individuals’ willingness and ability to work through them. An approach that may bridge the gap between facilitator-led and self-administered interventions is motivational interviewing (MI), a person-centered, collaborative counseling approach in which the clinician helps individuals explore and resolve ambivalence about behavior change, delivered in brief sessions.10 Motivational enhancement therapy (MET) is a manual-based adaptation of MI in which print feedback material based on personalized assessment is reviewed with the patient as part of an overall MI approach.11
The purpose of this study was to examine the efficacy of feedback reports alone, MI, and MET in promoting engagement in a full complement of ACP activities. The hypothesis was that each intervention would increase ACP engagement compared with usual care. In alignment with the recommendation to introduce ACP into the care of patients prior to the development of serious illness,12 the study was conducted among individuals recruited from outpatient primary care clinics.
Methods
Design and Setting
This was a single-blind randomized clinical trial recruiting participants from the primary care clinics at VA Connecticut Healthcare System. The VA has a robust practice of MI for substance use and health-related behavior change and an established process for MI training. There were 4 study groups to which participants were equally allocated: (1) computer-tailored print feedback, (2) MI, (3) MET, and (4) usual care. The study was approved by the Human Subjects Subcommittee of VA Connecticut and the institutional review board of the Yale School of Medicine. Full details regarding the trial protocol have been published (Supplement 1).13 The study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline.
Participants, Recruitment, and Enrollment
Potential participants were persons aged 55 years or older who had a primary care visit within the last year. The inclusion of middle-age and older adults selected for individuals more likely to have experienced the serious illness and death of a loved one. Women and persons whose ethnicity was recorded in the VA record as other than White were oversampled. Electronic health record review was performed to screen for the following exclusion criteria: diagnosis of dementia, severe hearing or vision loss, active psychiatric illness, primary language other than English, no regular access to a telephone, and no permanent mailing address. Potentially eligible persons were mailed an opt-out letter, followed by a telephone screen for further assessment of hearing, vision, and language; administration of the Brief Orientation Memory Concentration test, with a score greater than 10 used to identify moderate-to-severe cognitive impairment.14 The telephone screen also included stage of change for the 4 ACP behaviors that were the primary outcome for the study; participants who had completed all 4 behaviors were excluded. Because the entire study was conducted by telephone, verbal consent with a waiver of signature on the consent form was obtained from eligible individuals. Enrollment began October 2017 and follow-up was completed January 2021.
Randomization
Participants were randomized after completing the screening telephone call (Figure 1). Number of ACP behaviors completed at baseline may be the single variable most highly associated with the likelihood of full ACP engagement, because engagement is cross-sectionally associated with attitudes, beliefs, and processes related to ACP15 and to a number of sociodemographic characteristics16 and life experiences.17 A customized computer program used stratified permuted block randomization with a block length of 8, with stratification according to whether the participant had completed 0, 1 or 2, or 3 ACP behaviors to assign the study group in real time.
Figure 1. Flow of Participants Through the Study.
CTPF indicates computer-tailored print feedback; MI, motivational interviewing; MET, motivational enhancement therapy.
Study Group Procedures
The procedures are summarized in Figure 2. Participants randomized to CTPF completed a 10-minute telephone assessment that generated a personalized feedback report (eMethods in Supplement 2). Development and refinement of this intervention have been previously described.8 These reports provide information about ACP, discussion of ACP readiness, benefits and barriers, and specific next steps for engagement. The reports referenced 1 of 2 stage-matched brochures, detailed elsewhere.8 Participants received a pamphlet to give to potential surrogate decision makers to explain their role in ACP. Assessment and feedback occurred at baseline, 2, and 4 months, with materials delivered by mail.
Figure 2. Description of Study Procedures.
ACP indicates advance care planning; CTPF, computer-tailored print feedback; MI, motivational interviewing; MET, motivational enhancement therapy. Length of motivational interviews presented as mean +/− standard deviation minutes.
Participants randomized to MI and MET completed the same telephone assessments. Participants in the MI group did not receive the feedback reports or brochures. Within 2 weeks of each assessment, they had an MI session by telephone conducted by a health psychologist or psychology interns (total of 6 interventionists) who were trained in general MI via a 2-day workshop and received additional feedback during role-playing sessions in the delivery of MI for ACP.18 The interview, which required no advance preparation by the clinician, consisted of 4 steps: (1) elicitation and clarification of patient’s understanding of and current engagement in ACP; (2) building motivation for ACP; (3) developing a change plan; and (4) summarizing the overall discussion. MET sessions were conducted using the same manual; participants randomized to MET received the feedback report and brochures, and the counselor referred to these during the session. These sessions occurred at baseline, 2, and 4 months. Fidelity was assessed by measure of adherence to 5 fundamental (eg, open questions, affirmations, reflections) and 5 advanced MI strategies (eg, questions to directly elicit motivation, patient-centered feedback, change planning), 3 MI inconsistent strategies (eg, unsolicited advice), and 1 ACP-specific strategy of psychoeducation using the Independent Tape Rater Scale (ITRS)19 adapted for this study. Two external blinded raters evaluated a random sample of 5% of audio-recorded interviews, rating the extent and/or frequency of using each strategy along a 7-point Likert scale, with 1 indicating “not at all” and 7 indicating “extremely”. Mean scores for each set of items were calculated. Interrater reliability for these mean scores, measured using intraclass correlation coefficients (ICCs), was adequate for fundamental strategies (0.67) and good for the other strategies (0.75 to 0.78).20 ICCs could not be calculated for MI inconsistent strategies because they never occurred in rated samples.
Participants randomized to usual care completed assessments at baseline, 2 months, and 4 months but did not receive reports, brochures, or counseling. To minimize the effect of asking about ACP behaviors on participants’ engagement in these behaviors, control assessments concluded with questions about readiness to engage in physical activity.
Outcomes
The primary outcome was self-reported completion of all the following 4 ACP behaviors at 6 months ascertained through a telephone assessment administered by a research assistant blinded to group assignment: (1) communicating with a trusted other about views regarding quality vs quantity of life; (2) assignment of a health care agent; (3) completion of living will; (4) submitting written documents for inclusion in the electronic health record (EHR).
Additional Measures
Participant characteristics obtained during the baseline assessment included: age; gender; race and ethnicity, assessed with the 2 questions, “Are you Hispanic or Latinx?” and “Do you consider yourself American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Black or African American, White, More than one race, or Other?”; education; finances, assessed with the question, “At the end of the month, do you end up with some money left over, just enough to make ends meet, or not enough to make ends meet?;21 marital status; employment; living alone or with others; self-rated health22; and attendance at religious services, assessed with a measure from the Duke University Religion Index.23
Power and Sample Size
The sample size was calculated to detect an absolute increase of 10 percentage points for the primary outcome in each of the treatment groups as compared with the usual care group, estimating a 5% prevalence for the usual care group.16 A sample size of 110 per group was required to achieve a power of 0.80 with an α = .05. A 10% loss to follow-up was assumed, resulting in a sample size of 121 per group, for a total of 484.
Statistical Analysis
Univariate statistics were used to describe the sample. Analytic models used intention-to-treat analysis, including all participants who completed a baseline interview, regardless of adherence or missing data. In primary outcome analyses, a logistic regression model was used to compare each of the 3 intervention groups to the usual care group on completion of all 4 ACP activities. In secondary analysis, logistic regression models were used to examine completion of each individual ACP activity among those participants who had not completed that activity at baseline. The predicted probabilities of completing all 4 and each ACP activity were obtained by converting logistic regression coefficients from a log odds scale to a probability scale, while keeping coviariates at their mean levels. Participants with missing outcomes were assumed not to have completed the ACP activity, to produce conservative estimates of treatment effects. Sensitivity analyses for missing data were conducted using the last observation carried forward method to impute missing values. For all analyses, an unadjusted regression model was fitted first, followed by an adjusted model that controlled for participants’ age, educational attainment, race (White vs all other categories), gender, and baseline stage of each ACP activity. All analyses were performed using SAS version 9.4 (SAS Institute) from January to June 2022.
Results
Figure 1 provides a description of the participant flow. Of the 3050 individuals undergoing telephone screening, 1571 did not wish to participate and 991 were ineligible, with most (913) reporting that they had already completed the 4 ACP activities. The remaining 488 were randomized. After randomization, 5 participants reported at their baseline interview that they had completed the 4 ACP activities despite reporting during screening that they had not. Because they were no longer eligible, these participants were considered randomized in error. This resulted in final randomization of 123 to usual care, 121 to CTPF, 120 to MI, and 119 to MET. At 6 months, 92% to 97% of participants in each group completed 6-month assessments.
Table 1 presents participant baseline characteristics. Among the 483 randomized in this study, there were 88 women (18.2%), 119 African American or Black participants (24.6%), 15 Hispanic or Latinx participants (3.1%), 19 participants with more than 1 race (3.9%), and 333 White participants (68.9%); mean (SD) age was 68.3 (8.0) years; 148 (30.6%) had a high school education or less, 229 (47.4%) had just enough or not enough money to make ends meet, and 101 (20.9%) reported their health was fair or poor. Most characteristics were balanced across the groups. Although the groups were well matched according to the number of ACP behaviors they had completed at baseline, stage of change for assigning a health care agent and completing a living will differed across the groups.
Table 1. Characteristics of Study Participants at Baseline.
| Characteristic | Participants, No. (%) | ||||
|---|---|---|---|---|---|
| Usual care (n = 123) | CTPF (n = 121) | MI (n = 120) | MET (n = 119) | Total (n = 483) | |
| Age, mean (SD) | 68.54 (7.1) | 68.06 (8.1) | 69.15 (8.3) | 67.61 (8.5) | 68.34 (8.0) |
| Women | 24 (19.5) | 20 (16.5) | 22 (18.3) | 22 (18.5) | 88 (18.2) |
| Hispanic or Latinx | 3 (2.4) | 5 (4.1) | 2 (1.7) | 5 (4.2) | 15 (3.1) |
| Race | |||||
| African American or Black | 28 (22.8) | 32 (26.4) | 24 (20.0) | 35 (29.4) | 119 (24.6) |
| American Indian/Alaska Native | 0 | 1 (0.8) | 2 (1.7) | 0 | 3 (0.6) |
| Asian | 0 | 0 | 1 (0.8) | 0 | 1 (0.2) |
| White | 89 (72.4) | 80 (66.1) | 87 (72.5) | 77 (64.7) | 333 (68.9) |
| More than 1 race | 3 (2.4) | 7 (5.8) | 3 (2.5) | 6 (5.0) | 19 (3.9) |
| Did not respond | 3 (2.4) | 1 (0.8) | 3 (2.5) | 1 (0.8) | 8 (1.7) |
| Education ≤12th grade | 35 (28.5) | 40(33.1) | 38 (31.7) | 35 (29.4) | 148 (30.6) |
| Not enough or just enough money to make ends meet | 57 (46.3) | 62 (51.2) | 60 (50.5) | 50 (42.0) | 229 (47.4) |
| Married/partnered | 64 (52.0) | 62 (51.2) | 53 (44.2) | 65 (54.6) | 244 (50.5) |
| Employed | 51 (41.4) | 45 (37.2) | 40 (33.4) | 56 (47.1) | 192 (39.7) |
| Lives alone | 34 (27.6) | 36 (29.8) | 44 (36.7) | 31 (26.1) | 145 (30.0) |
| Attends religious service ≥1x/week | 35 (28.5) | 30 (24.8) | 39 (32.5) | 31 (26.3) | 135 (28.0) |
| Self-rated health fair or poor | 23 (18.7) | 25 (20.7) | 26 (21.7) | 27 (22.7) | 101 (20.9) |
| No. of ACP behaviors completed | |||||
| 0 | 45 (36.6) | 45 (37.2) | 39 (32.5) | 39 (32.8) | 168 (34.8) |
| 1-2 | 69 (56.1) | 68 (56.2) | 73 (60.8) | 68 (57.1) | 278 (57.5) |
| 3 | 9 (7.3) | 8 (6.6) | 8 (6.7) | 12 (10.1) | 37 (7.7) |
| Stage of change for communication with surrogate about quality vs quantity of life | |||||
| Precontemplation | 36 (29.3) | 34 (28.1) | 36 (30.0) | 30 (25.2) | 136 (28.2) |
| Contemplation | 16 (13.0) | 15 (12.4) | 13 (10.8) | 7 (5.9) | 51 (10.6) |
| Preparation | 1 (0.8) | 6 (5.0) | 5 (4.2) | 10 (8.4) | 22 (4.6) |
| Action/maintenance | 70 (56.9) | 66 (54.5) | 66 (55.0) | 72 (60.5) | 274 (56.8) |
| Stage of change for assigning a health care agent | |||||
| Precontemplation | 28 (22.8) | 19 (15.7) | 26 (21.7) | 26 (21.8) | 99 (20.5) |
| Contemplation | 56 (45.5) | 39 (32.2) | 42 (35.0) | 40 (33.6) | 177 (36.6) |
| Preparation | 19 (15.4) | 48 (39.7) | 32 (26.7) | 30 (25.2) | 129 (26.7) |
| Action/maintenance | 20 (16.3) | 15 (12.4) | 20 (16.7) | 23 (19.3) | 78 (16.1) |
| Stage of change for completing a living will | |||||
| Precontemplation | 19 (15.4) | 13 (10.7) | 22 (18.3) | 18 (15.1) | 72 (14.9) |
| Contemplation | 63 (51.2) | 43 (35.5) | 45 (37.5) | 47 (39.5) | 198 (41.0) |
| Preparation | 19 (15.4) | 41 (33.9) | 29 (24.2) | 32 (26.9) | 121 (25.1) |
| Action/maintenance | 22 (17.9) | 24 (19.9) | 24 (20.0) | 22 (18.5) | 92 (19.0) |
Abbreviations: ACP, advance care planning; CTPF, computer-tailored print feedback; MET, motivational enhancement therapy; MI, motivational interviewing.
Approximately 75% of participants assigned to MI and 80% assigned to MET completed 2 or 3 sessions (Table 2). Mean (SD) scores were 5.0 (0.7) for adherence to fundamental strategies, 3.1 (0.7) for advanced strategies, and 5 (1.5) for adherence to ACP education. No MI-discordant behaviors were observed.
Table 2. Participant Adherence to MI and MET.
| No. of sessions completed | Participants, No. (%) | |
|---|---|---|
| MI | MET | |
| 0 | 9 (7.5) | 11 (9.2) |
| 1 | 14 (11.7) | 18 (15.1) |
| 2 | 30 (25.0) | 29 (24.4) |
| 3 | 67 (55.8) | 61 (51.3) |
Abbreviations: MET, motivational enhancement therapy; MI, motivational interviewing.
In an unadjusted model, participants receiving MET and participants receiving MI were significantly more likely to achieve the primary outcome of completing all 4 ACP activities compared with participants who received usual care (MET: odds ratio [OR], 3.04; 95% CI, 1.34-6.87; MI: OR, 2.84; 1.25-6.46) (Table 3). Participants receiving CTPF were not significantly more likely to achieve the primary outcome (OR, 1.79; 95% CI, 0.75-4.27). The predicted probability of completing the 4 ACP activities was 7.3% (95% CI, 3.9%, 13.5%) in the usual care group, 19.3% (95% CI, 13.2%-27.4%) in the MET group, 18.3% (95% CI, 12.4%-26.3%) in the MI group, and 12.4% (95% CI, 7.6%-19.6%) in the CTPF group. The results from adjusted models were similar. The predicted probabilities of completing the 4 ACP activities were 5.7% (95% CI, 2.8%-11.1%) for usual care, 17.7% (95% CI, 11.8%-25.9%) for MET, 15.8% (95% CI, 10.2%-23.6%) for MI, and 10.0% (95% CI, 5.9%-16.7%) for CTPF.
Table 3. Effect of Written Feedback, MI, and MET on Completion of ACP Activities.
| 6-Month outcome | Study group | Unadjusted | Adjusted | ||||
|---|---|---|---|---|---|---|---|
| Odds ratio (95% CI) | Predicted probability (95% CI) | P value | Odds ratio (95% CI) | Predicted probability (95% CI) | P value | ||
| Completed all ACP activities | Usual care (n = 123)a | 1 [Reference] | 7.3 (3.9-13.5) | 1 [Reference] | 5.7 (2.8-11.1) | ||
| MET (n = 119) | 3.04 (1.34-6.87) | 19.3 (13.2-27.4) | .008 | 3.58 (1.52-8.43) | 17.7 (11.8-25.9) | .003 | |
| MI (n = 120) | 2.84 (1.25-6.46) | 18.3 (12.4-26.3) | .01 | 3.11 (1.32-7.34) | 15.8 (10.2-23.6) | .01 | |
| CTPF (n = 121) | 1.79 (0.75-4.27) | 12.4 (7.6-19.6) | .19 | 1.85 (0.75-4.57) | 10.0 (5.9-16.7) | .19 | |
| Communicated about quality vs quantity of life | Usual care (n = 53) | 1 [Reference] | 41.5 (29.1-55.1) | 1 [Reference] | 44.0 (30.8-58.2) | ||
| MET (n = 47) | 2.27 (1.02-5.07) | 61.7 (47.2-74.4) | .05 | 2.00 (0.85-4.69) | 61.1 (45.6-74.7) | .11 | |
| MI (n = 54) | 3.35 (1.50-7.44) | 70.4 (57.0-81.0) | .003 | 3.31 (1.44-7.61) | 72.2 (58.6-82.7) | .005 | |
| CTPF (n = 55) | 1.57 (0.73-3.36) | 52.7 (39.7-665.4) | .24 | 1.35 (0.60-3.02) | 51.5 (37.8-65.0) | .46 | |
| Appointed a health care agent | Usual care (n = 103) | 1 [Reference] | 23.3 (16.1-32.4) | 1 [Reference] | 22.8 (15.4-32.2) | ||
| MET (n = 96) | 2.35 (1.28-4.33) | 41.7 (32.3-51.7) | .006 | 2.46 (1.30-4.65) | 42.0 (32.2-52.5) | .006 | |
| MI (n = 100) | 2.59 (1.41-4.73) | 44.0 (34.6-53.8) | .002 | 2.63 (1.40-4.94) | 43.6 (33.8-54.0) | .003 | |
| CTPF (n = 106) | 1.69 (0.92-3.11) | 34.0 (25.6-43.5) | .09 | 1.45 (0.76-2.77) | 29.9 (21.6-39.8) | .26 | |
| Completed a living will | Usual care (n = 101) | 1 [Reference] | 19.8 (13.2-28.7) | 1 [Reference] | 19.5 (12,7-28.7) | ||
| MET (n = 97) | 3.09 (1.64-5.83) | 43.3 (33.8-53.3) | <.001 | 2.95 (1.52-5.71) | 41.6 (31.7-52.2) | .001 | |
| MI (n = 96) | 2.22 (1.17-4.23) | 35.4 (26.5-45.5) | .01 | 2.07 (1.06-4.06) | 33.3 (24.2-44.0) | .03 | |
| CTPF (n = 97) | 1.64 (0.85-3.17) | 28.9 (20.7-38.6) | .14 | 1.36 (0.68-2.74) | 24.8 (16.9-34.8) | .38 | |
Abbreviations: ACP, advance care planning; CTPF, computer-tailored print feedback; MET, motivational enhancement therapy; MI, motivational interviewing.
Number of participants who had not completed the given ACP activity(ies) at baseline.
The receipt of MI or MET also was associated with increased likelihood of completing each individual ACP behavior (see Table 3), except for MET and communicating about quality vs quantity of life. Sensitivity analysis carrying the last value forward for missing data yielded similar results for both the primary and secondary outcomes.
Discussion
In this study of middle-age and older veterans attending primary care clinics, with oversampling of women and people from minoritized racial and ethnic groups, a series of brief MI and MET sessions significantly increased the likelihood of completing a full set of ACP activities compared with usual care, but brief assessment and delivery of print feedback materials did not. MI and MET also significantly increased the likelihood of completing most individual ACP activities.
This study used a comprehensive definition of ACP, in which a participant had to identify a trusted other, communicate with this person about quality vs quantity of life, assign a health care agent, complete an instructional advance directive, and submit these forms for inclusion in the EHR. The inclusion of communication and relationship with loved ones is critical to complementing the inherent limitations of written directives.2 This approach differs from many other interventions conducted in the ambulatory setting, which have considered engagement in any single component of ACP as a successful outcome.24
The interventions used in this study were selected to begin to provide insights into the trade-offs between cost and efficacy in different approaches to the promotion of behavior change. The delivery of print materials can be done at substantially lower cost than the delivery of MI or MET. While clinical experience would suggest that interventions based on personal interaction would be more effective than written feedback alone, there have been few head-to-head studies, and the few that have been done have not demonstrated differences in efficacy.25,26 The predicted probability for the print feedback was smaller than in a prior study performed among individuals recruited from community ambulatory care practices8 and was smaller than what was hypothesized, such that the current study was underpowered to detect this effect size. In that prior study, the initial feedback materials were handed to the patient by the research staff with whom a relationship had been established during the course of enrolling the patient and conducting an assessment. That mode of delivery, compared with the current study, in which materials were sent through the mail in an envelope that may or may not have been opened, may have been more likely to result in review of the materials.
Both MI and MET demonstrated more robust effects on promoting engagement in both the full complement of ACP activities and on individual activities. Although MI is more resource-intensive than written feedback, it can be taught with modest resources. In one study, MI was effectively taught to a variety of staff in a primary care clinic in 3 sessions consisting of 2 half-day in-person sessions and 1 60-minute virtual session.27 MI can also be self-taught and taught using a train-the-trainer model.28 In the current study, the MI and MET clinicians received a 2-day general training in MI followed by review of the MI/MET manual, several practice cases, and monthly supervision. Given that MI has also been shown to reduce problematic behaviors, such as alcohol use disorder, and increase healthy behaviors, such as exercise,29 investments in MI training may result in practitioners who are prepared and able to address a range of issues among primary care patients. The MET intervention was MI supplemented with print feedback, and was demonstrated, in contrast with the results in this study, a meta-analysis that found MET to be more effective than MI.30
Engagement in ACP has unique features that may be uniquely well addressed by MI. Patients often express deep ambivalence about engaging in end-of-life planning and/or experience ambivalence among their loved ones.31 Our adherence scores indicated that, on average, basic relational skills of MI were used frequently, with less frequent use of the more advanced MI strategies, although these scores are consistent with levels of adherence demonstrated in other MI and MET clinical trials.19,32 More work is needed to understand how MI can best be used to support individuals’ engagement in ACP.
Limitations
This study has several limitations. We used self-report for ascertainment of outcomes, which may have been subject to desirability bias. While we had very little missing data at 6 months, there was a larger proportion of missing data at 2 and 4 months. The study was conducted at a single VA site. Although we oversampled women and persons from minoritized racial and ethnic groups, the study cohort was majority male and White.
Conclusion
This randomized clinical trial found MI to be effective for increasing engagement in a full range of ACP activities among middle-aged and older veterans receiving primary care at the VA. These findings suggests that MI provides a clinician-directed approach to ACP that can address barriers to engagement and results in higher rates of engagement than the use of print feedback.
Trial Protocol
eMethods. Assessment of Readiness to Engage in Advance Care Planning Used to Generate Computer-Tailored Print Feedback
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Trial Protocol
eMethods. Assessment of Readiness to Engage in Advance Care Planning Used to Generate Computer-Tailored Print Feedback
Data Sharing Statement