Effect of the STAMP (Sharing and Talking About My Preferences) Intervention on Completing Multiple Advance Care Planning Activities in Ambulatory Care : A Cluster Randomized Controlled Trial

Abstract

Background: Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning.

Objective: To examine the effect of a computer-tailored, behavioral health model-based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings.

Design: Cluster randomized controlled trial with participant-level analysis. (ClinicalTrials.gov: NCT03137459).

Setting: 10 pairs of primary and selected specialty care practices matched on patient sociodemographic information.

Participants: English-speaking adults aged 55 years or older; 454 adults at practices randomly assigned to usual care and 455 at practices randomly assigned to intervention.

Intervention: Brief telephone or web-based assessment generating a mailed, individually tailored feedback report with a stage-matched brochure at baseline, 2 months, and 4 months.

Measurements: The primary outcome was completion of the following 4 advance care planning activities at 6 months: identifying and communicating with a trusted person about views on quality versus quantity of life, assignment of a health care agent, completion of a living will, and ensuring that the documents are in the medical record-assessed by a blinded interviewer. Secondary outcomes were completion of individual advance care planning activities.

Results: Participants were 64% women and 76% White. The mean age was 68.3 years (SD, 8.3). The predicted probability of completing all advance care planning activities in usual care sites was 8.2% (95% CI, 4.9% to 11.4%) versus 14.1% (CI, 11.0% to 17.2%) in intervention sites (adjusted risk difference, 5.2 percentage points [CI, 1.6 to 8.8 percentage points]). Prespecified subgroup analysis found no statistically significant interactions between the intervention and age, education, or race.

Limitations: The study was done in a single region and excluded non-English speaking participants. No information was collected about nonparticipants.

Conclusion: A brief, easily delivered, tailored print intervention increased participation in advance care planning in ambulatory care settings.

Primary funding source: National Institute of Nursing Research and National Institute of Aging.

Figures

Figure 1:

Flow of participants through study

Figure 2:

Effect of the intervention in pre-specified subgroups, adjusting for clustering within practice site. OR = Odds ratio LL = Lower Limit UL = Upper Limit. See Supplement Table 2 for results additionally adjusted for education, employment, and baseline stage of change for completion of a living will, assignment of a health care agent, and communication about quality versus quantity of life