Advance care planning among outpatients may improve with low-tech intervention

A randomized trial at primary and specialty care practices in Connecticut compared completion rates of four advance care planning activities in patients who received an internet- or telephone-based intervention assessing readiness to participate versus those receiving usual care.

A low-tech intervention individually tailored to outpatients' needs helped improve participation in advance care planning, according to a recent study.

Researchers in the VA Connecticut Healthcare System randomly assigned 10 pairs of primary care and selected specialty care practices to usual care or to the STAMP (Sharing and Talking About My Preferences) program. Patients in practices assigned to the intervention received a brief telephone- or web-based assessment on readiness to participate in advance care planning behaviors or activities, which generated a mailed, individually tailored feedback report with a stage-matched brochure at baseline, two months, and four months. Completion of four advance care planning activities were compared between study groups at six months: identifying and communicating with a trusted person about views on quality versus quantity of life, assigning a health care agent, completing a living will, and ensuring that the documents are in the medical record. The results of the trial were published Aug. 31 by Annals of Internal Medicine.

A total of 454 adults at the usual care practices and 455 adults at the intervention practices were included in the study. All were English-speaking adults ages 55 years or older, with a mean age of 68.3 years. Sixty-four percent were women, and 76% were White. The predicted probability of completing all advance care planning activities was 8.2% (95% CI, 4.9% to 11.4%) at usual care sites versus 14.1% (95% CI, 11.0% to 17.2%) at intervention sites (adjusted risk difference, 5.2 percentage points [95% CI, 1.6 to 8.8 percentage points]). In a prespecified subgroup analysis, no statistically significant interactions were found between the intervention and age, education, or race.

The authors noted that the study was done in only one region among only English-speaking participants, among other limitations. They concluded that the STAMP program was effective at increasing advance care planning among middle-age and older adults in primary and specialty care. Because the intervention can be delivered by a variety of methods, including via the internet and by telephone and mail, it is feasible as a population-based approach to increasing patients' engagement in advance care planning, the authors wrote.

An accompanying editorial noted that the overall effect was modest and called for future studies to focus on diverse participants but agreed that the STAMP intervention's adaptability to different delivery methods increases its accessibility. “[E]vidence-based interventions like STAMP can play an important role in supporting patients and their families in identifying goals for care, imagining and planning for obstacles, and adjusting goals when obstacles are insurmountable to help prepare for future decision making during serious illness and at the end of life,” the editorialists wrote.