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Geriatrics

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

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
JAMA Network Open
Published Online: February 24, 2022
Original Investigation
Angelo E. Volandes, MD, MPH1,2,3;
Sophia N. Zupanc, BA4;
Michael K. Paasche-Orlow, MD, MPH, MA5;
Joshua R. Lakin, MD1,4,6;
Yuchiao Chang, PhD1,2;
Edith A. Burns, MD7,8;
Nancy A. LaVine, MD7,8;
Maria T. Carney, MD7,8;
Diana Martins-Welch, MD7,8;
Kaitlin Emmert, LMSW7;
Jennifer E. Itty, MPH7;
Edward T. Moseley, BS9;
Aretha D. Davis, MD, JD3;
Areej El-Jawahri, MD1,2;
Daniel A. Gundersen, PhD9;
Gemmae M. Fix, PhD5,10;
Andrea M. Yacoub, MPH7;
Pamela Schwartz, BS3;
Shira Gabry-Kalikow, LMSW, MPH3;
Cynthia Garde, MBA3;
Jonathan Fischer, MD11;
Lori Henault, MPH5;
Leah Burgess, MHA7;
Julie Goldman, MS, MSW4;
Anne Kwok, BA4;
Nimisha Singh, MPH7;
Armando L. Alvarez Suarez, BS7;
Valeria Gromova, BS7;
Sonia Jacome, MSCH7;
James A. Tulsky, MD1,4,6;
Charlotta Lindvall, MD, PhD1,4,6
Author Affiliations
  • 1Harvard Medical School, Boston, Massachusetts
  • 2Department of Medicine, Massachusetts General Hospital, Boston
  • 3ACP Decisions, Boston, Massachusetts
  • 4Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 5Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
  • 6Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 7Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
  • 8Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
  • 9Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 10Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts
  • 11Department of Community Health and Family Medicine, Hospice and Palliative Care, Duke University Health System, Durham, North Carolina
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Key Points

Question  Can an advance care planning (ACP) video and communication intervention promote ACP for elderly patients during the ongoing COVID-19 pandemic?

Findings  This pre-post, open-cohort nonrandomized controlled trial compared ACP documentation during three 6-month periods: pre–COVID-19 (14 107 patients), COVID-19 wave 1 (12 806 patients), and an intervention period (15 106 patients). The ACP documentation rates were 17.9% in the pre–COVID-19 period, 12.5% in the COVID-19 wave 1 period, and 23.7% in the intervention period; ACP rates during the intervention period were highest compared with the 2 other periods.

Meaning  The use of an ACP video and communication intervention may promote ACP for elderly adults during the evolving COVID-19 pandemic.

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

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Geriatrics End of Life Shared Decision Making and Communication Mobile Health and Telemedicine Coronavirus (COVID-19)
Article Information

Accepted for Publication: January 3, 2022.

Published: February 24, 2022. doi:10.1001/jamanetworkopen.2022.0354

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Volandes AE et al. JAMA Network Open.

Corresponding Author: Angelo E. Volandes, MD, MPH, Department of Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 (avolandes@partners.org).

Author Contributions: Dr Volandes had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Tulsky and Lindvall are co–senior authors.

Concept and design: Volandes, Paasche-Orlow, Chang, LaVine, Carney, Martins-Welch, Davis, El-Jawahri, Fix, Garde, Fischer, Singh, Jacome, Tulsky, Lindvall.

Acquisition, analysis, or interpretation of data: Volandes, Zupanc, Lakin, Chang, Burns, LaVine, Carney, Emmert, Itty, Moseley, Gundersen, Yacoub, Schwartz, Gabry-Kalikow, Henault, Burgess, Goldman, Kwok, Singh, Alvarez Suarez, Gromova, Tulsky, Lindvall.

Drafting of the manuscript: Volandes, Zupanc, Chang, Carney, Itty, El-Jawahri, Yacoub, Schwartz, Burgess, Alvarez Suarez, Gromova, Lindvall.

Critical revision of the manuscript for important intellectual content: Volandes, Paasche-Orlow, Lakin, Burns, LaVine, Martins-Welch, Emmert, Moseley, Davis, El-Jawahri, Gundersen, Fix, Gabry-Kalikow, Garde, Fischer, Henault, Goldman, Kwok, Singh, Jacome, Tulsky, Lindvall.

Statistical analysis: Volandes, Chang, Emmert, Burgess, Singh.

Obtained funding: Volandes, Burns, Tulsky.

Administrative, technical, or material support: Volandes, Zupanc, Paasche-Orlow, Lakin, Burns, LaVine, Carney, Emmert, Itty, Moseley, Davis, El-Jawahri, Yacoub, Schwartz, Gabry-Kalikow, Fischer, Henault, Goldman, Kwok, Jacome, Tulsky, Lindvall.

Supervision: Volandes, Burns, Carney, Moseley, Davis, Garde, Tulsky, Lindvall.

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.

Funding/Support: This work is supported within the NIH Health Care Systems Research Collaboratory by the NIH Common Fund through cooperative agreement UG3AG060626 from the National Institute on Aging. Supplemental funding for this work was provided by the NIH Common Fund under award 3UH3AG060626-03S1 from the Office of Strategic Coordination within the Office of the NIH Director. This work also received logistical and technical support from the NIH Collaboratory Coordinating Center through cooperative agreement U24AT009676.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views presented here are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Data Sharing Statement: See Supplement 3.

Additional Contributions: Marcel Salive, MD, MPH, National Institute on Aging, and Jeri Miller, PhD, MS, MSc, National Institute of Nursing Research, provided review and guidance of this trial. They were not compensated for their assistance.

References
1.
Centers for Disease Control and Prevention. COVID data tracker. Accessed October 18, 2021. https://covid.cdc.gov/covid-data-tracker/#demographicsovertime
2.
Curtis  JR , Kross  EK , Stapleton  RD .  The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19).   JAMA. 2020;323(18):1771-1772. doi:10.1001/jama.2020.4894 PubMedGoogle Scholar
3.
Sudore  RL , Lum  HD , You  JJ ,  et al.  Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel.   J Pain Symptom Manage. 2017;53(5):821-832.e1. doi:10.1016/j.jpainsymman.2016.12.331 PubMedGoogle ScholarCrossref
4.
Sudore  RL , Fried  TR .  Redefining the “planning” in advance care planning: preparing for end-of-life decision making.   Ann Intern Med. 2010;153(4):256-261. doi:10.7326/0003-4819-153-4-201008170-00008 PubMedGoogle ScholarCrossref
5.
Sudore  RL , Heyland  DK , Lum  HD ,  et al.  Outcomes that define successful advance care planning: a delphi panel consensus.   J Pain Symptom Manage. 2018;55(2):245-255.e8. doi:10.1016/j.jpainsymman.2017.08.025 PubMedGoogle ScholarCrossref
6.
National Academies of Sciences, Engineering, and Medicine.  The Challenges and Opportunities of Advance Care Planning: Proceedings of a Workshop. National Academies Press; 2021.
7.
Hopkins  SA , Lovick  R , Polak  L ,  et al.  Reassessing advance care planning in the light of COVID-19.   BMJ. 2020;369:m1927. doi:10.1136/bmj.m1927 PubMedGoogle Scholar
8.
El-Jawahri  A , Podgurski  LM , Eichler  AF ,  et al.  Use of video to facilitate end-of-life discussions with patients with cancer: a randomized controlled trial.   J Clin Oncol. 2010;28(2):305-310. doi:10.1200/JCO.2009.24.7502 PubMedGoogle ScholarCrossref
9.
El-Jawahri  A , Mitchell  SL , Paasche-Orlow  MK ,  et al.  A randomized controlled trial of a CPR and intubation video decision support tool for hospitalized patients.   J Gen Intern Med. 2015;30(8):1071-1080. doi:10.1007/s11606-015-3200-2 PubMedGoogle ScholarCrossref
10.
El-Jawahri  A , Paasche-Orlow  MK , Matlock  D ,  et al.  Randomized, controlled trial of an advance care planning video decision support tool for patients with advanced heart failure.   Circulation. 2016;134(1):52-60. doi:10.1161/CIRCULATIONAHA.116.021937 PubMedGoogle ScholarCrossref
11.
Back  AL , Arnold  RM , Tulsky  JA , Baile  WF , Fryer-Edwards  KA .  Teaching communication skills to medical oncology fellows.   J Clin Oncol. 2003;21(12):2433-2436. doi:10.1200/JCO.2003.09.073 PubMedGoogle ScholarCrossref
12.
Volandes  AE , Lehmann  LS , Cook  EF , Shaykevich  S , Abbo  ED , Gillick  MR .  Using video images of dementia in advance care planning.   Arch Intern Med. 2007;167(8):828-833. doi:10.1001/archinte.167.8.828 PubMedGoogle ScholarCrossref
13.
Volandes  AE , Paasche-Orlow  MK , Barry  MJ ,  et al.  Video decision support tool for advance care planning in dementia: randomised controlled trial.   BMJ. 2009;338:b2159. doi:10.1136/bmj.b2159 PubMedGoogle ScholarCrossref
14.
Mitchell  SL , Volandes  AE , Gutman  R ,  et al.  Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial.   JAMA Intern Med. 2020;180(8):1070-1078. doi:10.1001/jamainternmed.2020.2366 PubMedGoogle ScholarCrossref
15.
Lakin  JR , Block  SD , Billings  JA ,  et al.  Improving communication about serious illness in primary care: a review.   JAMA Intern Med. 2016;176(9):1380-1387. doi:10.1001/jamainternmed.2016.3212 PubMedGoogle ScholarCrossref
16.
McMahan  RD , Tellez  I , Sudore  RL .  Deconstructing the complexities of advance care planning outcomes: what do we know and where do we go? a scoping review.   J Am Geriatr Soc. 2021;69(1):234-244. doi:10.1111/jgs.16801 PubMedGoogle ScholarCrossref
17.
Monaghesh  E , Hajizadeh  A .  The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence.   BMC Public Health. 2020;20(1):1193. doi:10.1186/s12889-020-09301-4 PubMedGoogle ScholarCrossref
18.
NYC Health. COVID-19: data. Accessed October 5, 2021. https://www1.nyc.gov/site/doh/covid/covid-19-data.page
19.
Hershfield  H , Carstensen  L .  Your messaging to older audiences is outdated.   Harvard Business Rev. July 2, 2021. Accessed October 5, 2021. https://hbr.org/2021/07/your-messaging-to-older-audiences-is-outdatedGoogle Scholar
20.
Deep  KS , Hunter  A , Murphy  K , Volandes  A .  “It helps me see with my heart”: how video informs patients’ rationale for decisions about future care in advanced dementia.   Patient Educ Couns. 2010;81(2):229-234. doi:10.1016/j.pec.2010.02.004 PubMedGoogle ScholarCrossref
21.
Volandes  AE , Barry  MJ , Wood  F , Elwyn  G .  Audio-video decision support for patients: the documentary genré as a basis for decision aids.   Health Expect. 2013;16(3):e80-e88. doi:10.1111/j.1369-7625.2011.00727.x PubMedGoogle ScholarCrossref
22.
Back  AL , Arnold  RM , Baile  WF ,  et al.  Efficacy of communication skills training for giving bad news and discussing transitions to palliative care.   Arch Intern Med. 2007;167(5):453-460. doi:10.1001/archinte.167.5.453 PubMedGoogle ScholarCrossref
23.
Back  A , Tulsky  JA , Arnold  RM .  Communication skills in the age of COVID-19.   Ann Intern Med. 2020;172(11):759-760. doi:10.7326/M20-1376 PubMedGoogle ScholarCrossref
24.
Childers  JW , Back  AL , Tulsky  JA , Arnold  RM .  REMAP: a framework for goals of care conversations.   J Oncol Pract. 2017;13(10):e844-e850. doi:10.1200/JOP.2016.018796 PubMedGoogle ScholarCrossref
25.
Lindvall  C , Deng  CY , Moseley  E ,  et al.  Natural language processing to identify advance care planning documentation in a multisite pragmatic clinical trial.   J Pain Symptom Manage. 2022;63(1):e29-e36. doi:10.1016/j.jpainsymman.2021.06.025PubMedGoogle ScholarCrossref
26.
Brizzi  K , Zupanc  SN , Udelsman  BV ,  et al.  Natural language processing to assess palliative care and end-of-life process measures in patients with breast cancer with leptomeningeal disease.   Am J Hosp Palliat Care. 2020;37(5):371-376. doi:10.1177/1049909119885585 PubMedGoogle ScholarCrossref
27.
Lee  KC , Udelsman  BV , Streid  J ,  et al.  Natural language processing accurately measures adherence to best practice guidelines for palliative care in trauma.   J Pain Symptom Manage. 2020;59(2):225-232.e2. doi:10.1016/j.jpainsymman.2019.09.017 PubMedGoogle ScholarCrossref
28.
Poort  H , Zupanc  SN , Leiter  RE , Wright  AA , Lindvall  C .  Documentation of palliative and end-of-life care process measures among young adults who died of cancer: a natural language processing approach.   J Adolesc Young Adult Oncol. 2020;9(1):100-104. doi:10.1089/jayao.2019.0040 PubMedGoogle ScholarCrossref
29.
Udelsman  BV , Lilley  EJ , Qadan  M ,  et al.  Deficits in the palliative care process measures in patients with advanced pancreatic cancer undergoing operative and invasive nonoperative palliative procedures.   Ann Surg Oncol. 2019;26(13):4204-4212. doi:10.1245/s10434-019-07757-2 PubMedGoogle ScholarCrossref
30.
Lindvall  C , Lilley  EJ , Zupanc  SN ,  et al.  Natural language processing to assess end-of-life quality indicators in cancer patients receiving palliative surgery.   J Palliat Med. 2019;22(2):183-187. doi:10.1089/jpm.2018.0326 PubMedGoogle ScholarCrossref
31.
Lakin  JR , Gundersen  DA , Lindvall  C ,  et al; ACP-PEACE Investigators.  A yet unrealized promise: structured advance care planning elements in the electronic health record.   J Palliat Med. 2021;24(8):1221-1225. doi:10.1089/jpm.2020.0774 PubMedGoogle ScholarCrossref
32.
Pedroza  C , Truong  VT .  Performance of models for estimating absolute risk difference in multicenter trials with binary outcome.   BMC Med Res Methodol. 2016;16(1):113. doi:10.1186/s12874-016-0217-0 PubMedGoogle ScholarCrossref
33.
Curtis  JR .  Three stories about the value of advance care planning.   JAMA. 2021;326(21):2133-2134. doi:10.1001/jama.2021.21075 PubMedGoogle ScholarCrossref
34.
Pelland  K , Morphis  B , Harris  D , Gardner  R .  Assessment of first-year use of Medicare’s advance care planning billing codes.   JAMA Intern Med. 2019;179(6):827-829. doi:10.1001/jamainternmed.2018.8107 PubMedGoogle ScholarCrossref
35.
NCQA. HEDIS measurement year 2022. Accessed October 5, 2021. https://www.ncqa.org/hedis/measures
36.
Barrett  M , Coffey  R , Houchens  R , Heslin  K , Moles  E , Coenen  N . Methods applying AHRQ quality indicators to Healthcare Cost and Utilization Project (HCUP) data for the 2017 National Healthcare Quality and Disparities Report (QDR). HCUP Methods Series Report 2018-01. US Agency for Healthcare Research and Quality. May 11, 2018. Accessed October 5, 2021. http://www.hcup-us.ahrq.gov/reports/methods/methods.jsp
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