Pragmatic Trial to Increase Advance Care Planning: Anne Walling, Neil Wenger, & Rebecca Sudore

Today we’re delighted to talk with Anne Walling, Neil Wenger, and Rebecca Sudore about a pragmatic implementation trial aimed at increasing advance care planning for primary care patients with serious illness in University of California clinics, published in Annals of Internal Medicine. Seriously ill primary care patients were identified using structured data fields (meaning routinely captured without needing to read the chart or use natural language processing).

This study focused on patients without a completed advance directive or POLST form. This was a 3 arm trial that tested a nudge in the patient portal and a mailed advanced directive vs. the nudge plus a link to PrepareForYourCare vs. the nudge plus PrepareForYourCare plus a navigator reminding patients to talk with their doctor and bring any completed advance directives or POLST forms to the PCP visit.

In brief, the study found that at 2 years there were higher rates of advance directive or POLST in the electronic health record (about 20%) in the arm with the nudge plus PrepareForYourCare plus the navigator compared to the other 2 arms (around 13%). Rates of advance care planning discussions with primary care providers were similarly higher in the 3rd arm. Health care utilization, however, did not differ between arms.  Please see links to articles describing the intervention in detail and incorporation of stakeholder perspectives.

I’m going to cut to the pushback to this article right up front: 

• The study’s primary outcomes were advanced directives or completion of POLST forms - haven’t we moved beyond thinking completion of forms should be the primary outcome of advance care planning research?

• There was no control condition. Observed increases in advance directive or POLST in the electronic health record may have occurred without any intervention.  People with serious illness get sicker with time and the sicker they are the more likely they are to engage in advance care planning, without any intervention. This is particularly true as the study occurred during the hight of the Covid pandemic, when there was a global effort to increase advance care planning. How much did these interventions contribute on top of that rise that might have occurred without intervention? 

• Observed documentation - 13-20% - was low.  Is it worth the effort of getting buy-in to automate these EHR nudges and spend FTE to hire a navigator? Particularly as health systems, who pushed for focusing on seriously ill patients because they are the most expensive/highest utilizers, did not get what they wanted, i.e. no difference in utilization of acute healthcare services between arms?

Our guests provide a strong defense and additional context, which you can and should listen to on the podcast. And I have to point out, setting aside the advance care planning aspect, the method of identifying upstream primary care patients with serious illness is a major contribution to the field in and of itself.  Pioneers in the field, led by Amy Kelley, have been working to identify the seriously ill population for over a decade.

And a fun fact about All You Need is Love - the verses are in 7/4 time!

-Alex Smith