Empowering Older Adults to Discuss Advance Care Planning During Clinical Visits: The PREPARE Randomized Trial

• Published in: Journal of the American Geriatrics Society (JAGS) 2020-06, Vol.68 (6), p.1210-1217
• Main Authors: Freytag, Jennifer, Street, Richard L., Barnes, Deborah E., Shi, Ying, Volow, Aiesha M., Shim, Janet K., Alexander, Stewart C., Sudore, Rebecca L.
• Format: Article
• Language: English
• Subjects: Advance Care Planning; Advance Directives; Aged; aging; Chronic Disease - therapy; Clinical decision making; Clinical trials; Communication; Decision making; Documentation; Female; Health education; Health Literacy; Hospitals, Veterans; Humans; Internet; Male; Older people; Participation; Patient Participation; Patients; patient‐physician communication; Primary care; Primary Health Care; Regression analysis; San Francisco
• ISSN: 0002-8614; 1532-5415
• DOI: 10.1111/jgs.16405

BACKGROUND/OBJECTIVES A patient‐directed, online program (PREPARE for Your Care [PREPARE]; prepareforyourcare.org) has been shown to increase advance care planning (ACP) documentation. However, the mechanisms underlying PREPARE are unknown. Our objectives were to compare the efficacy of PREPARE plus an easy‐to‐read advance directive (AD) vs an AD alone to increase active patient participation in ACP discussions during clinic visits and to examine effects of active patient participation on ACP documentation. DESIGN Audio recordings of postintervention primary care visits from two randomized trials (2013‐2016). SETTING Seven primary care clinics at a veterans affair and safety‐net hospital in San Francisco, CA. PARTICIPANTS English‐ and Spanish‐speaking adults, aged 55 years and older, with two or more chronic/serious conditions. INTERVENTION PREPARE plus an easy‐to‐read AD or an AD alone. MEASUREMENTS The primary outcome was the number of active patient participation utterances about ACP (eg, asking questions, stating preferences) measured by the validated Active Patient Participation Coding Scheme. We examined differences in utterances by study arm using mixed effects negative binomial models and utterances as a mediator of PREPARE's effect on documentation using adjusted logistic regression. Models were adjusted for health literacy, prior care planning, and clinician. RESULTS Among 393 participants, the mean (SD) age was 66 (8.1) years, 120 (30.5%) had limited health literacy, and 99 (25.2%) were Spanish speaking. PREPARE plus the AD resulted in 41% more active patient participation in ACP discussions compared with the AD alone (mean [SD] = 10.1 [16.8] vs 6.6 [13.4] utterances; incidence rate ratio = 1.41; 95% confidence interval = 1.00‐1.98). For every additional utterance, participants had 15% higher odds of ACP documentation, and active patient participation accounted for 16% of PREPARE's effect on documentation. CONCLUSIONS The PREPARE program and easy‐to‐read AD empowered patients to actively participate in ACP discussions during clinical visits more than the AD alone. Increased activation was associated with increased ACP documentation. Therefore, PREPARE may mitigate barriers to ACP among English‐ and Spanish‐speaking older adults. TRIAL REGISTRATION ClinicalTrials.gov identifiers: “Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)” NCT01990235 and “Preparing Spanish‐Speaking Older Adults for Advance Care Pl