Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial

Angelo E Volandes, Sophia N Zupanc, Michael K Paasche-Orlow, Joshua R Lakin, Yuchiao Chang, Edith A Burns, Nancy A LaVine, Maria T Carney, Diana Martins-Welch, Kaitlin Emmert, Jennifer E Itty, Edward T Moseley, Aretha D Davis, Areej El-Jawahri, Daniel A Gundersen, Gemmae M Fix, Andrea M Yacoub, Pamela Schwartz, Shira Gabry-Kalikow, Cynthia Garde, Jonathan Fischer, Lori Henault, Leah Burgess, Julie Goldman, Anne Kwok, Nimisha Singh, Armando L Alvarez Suarez, Valeria Gromova, Sonia Jacome, James A Tulsky, Charlotta Lindvall, Angelo E Volandes, Sophia N Zupanc, Michael K Paasche-Orlow, Joshua R Lakin, Yuchiao Chang, Edith A Burns, Nancy A LaVine, Maria T Carney, Diana Martins-Welch, Kaitlin Emmert, Jennifer E Itty, Edward T Moseley, Aretha D Davis, Areej El-Jawahri, Daniel A Gundersen, Gemmae M Fix, Andrea M Yacoub, Pamela Schwartz, Shira Gabry-Kalikow, Cynthia Garde, Jonathan Fischer, Lori Henault, Leah Burgess, Julie Goldman, Anne Kwok, Nimisha Singh, Armando L Alvarez Suarez, Valeria Gromova, Sonia Jacome, James A Tulsky, Charlotta Lindvall

Abstract

Importance: COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models.

Objective: To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients.

Design, setting, and participants: The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included.

Main outcomes and measures: The primary outcome was ACP documentation.

Results: A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001).

Conclusions and relevance: This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients.

Trial registration: ClinicalTrials.gov Identifier: NCT04660422.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Volandes reported receiving personal fees from the Nous Foundation (dba ACP Decisions) outside the submitted work. Dr Lakin reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Chang reported receiving grants from the NIH during the conduct of the study. Dr Burns reported receiving grants from the NIH during the conduct of the study. Dr Davis reported receiving grants from the Nous Foundation (dba ACP Decisions) and serving as a former employee of Nous Foundation and currently as an unpaid volunteer outside the submitted work. Dr Fischer reported receiving personal fees from VitalTalk during the conduct of the study and outside the submitted work. Dr Tulsky reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. Study Timeline With Overlay of…
Figure 1.. Study Timeline With Overlay of COVID-19 Cases in New York City
Figure 2.. Video Views Stratified by Language
Figure 2.. Video Views Stratified by Language
ACP indicates advance care planning.
Figure 3.. Rates of Advance Care Planning…
Figure 3.. Rates of Advance Care Planning (ACP) Documentation Overall and Among Minority Subgroups in the 3 Study Periods

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