Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study

Wu, Adela; Huang, Robert J.; Colón, Gabriela Ruiz; Zembrzuski, Chris

doi:10.1186/s12904-022-01099-9

Cited by 6 publications

(5 citation statements)

References 24 publications

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“…This study supports use of multilevel interventions in tertiary, academic settings, where clinician-level interventions alone may be less effective for ACP . Unlike prior work in community clinics, in which LHW approaches alone were tested, in this study, we found no effect on frequency of ED use or the proportion of participants with ED use.…”

Section: Discussionsupporting

confidence: 69%

Coaches Activating, Reaching, and Engaging Patients to Engage in Advance Care Planning

Rodriguez,

Parikh,

Kapphahn

et al. 2024

JAMA Oncol

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ImportanceAdvance care planning (ACP) remains low among patients with advanced cancer. Multilevel interventions compared with clinician-level interventions may be more effective in improving ACP.ObjectiveTo evaluate whether a multilevel intervention could improve clinician-documented ACP compared with a clinician-level intervention alone.Design, Setting, and ParticipantsThis randomized clinical trial, performed from September 12, 2019, through May 12, 2021, included adults with advanced genitourinary cancers at an academic, tertiary hospital. Data analysis was performed by intention to treat from May 1 to August 10, 2023.InterventionParticipants were randomized 1:1 to a 6-month patient-level lay health worker structured ACP education along with a clinician-level intervention composed of 3-hour ACP training and integration of a structured electronic health record documentation template (intervention group) or to the clinician-level intervention alone (control group).Main Outcome and MeasuresThe primary outcome was ACP documentation in the electronic health record by the oncology clinician within 12 months after randomization. Secondary, exploratory outcomes included shared decision-making, palliative care use, hospice use, emergency department visits, and hospitalizations within 12 months after randomization.ResultsAmong 402 participants enrolled in the study, median age was 71 years (range, 21-102 years); 361 (89.8%) identified as male. More intervention group participants had oncology clinician–documented ACP than control group participants (82 [37.8%] vs 40 [21.6%]; odds ratio [OR], 2.29; 95% CI, 1.44-3.64). At 12-month follow-up, more intervention than control group participants had palliative care (72 [33.2%] vs 25 [13.5%]; OR, 3.18; 95% CI, 1.91-5.28) and hospice use (49 [22.6%] vs 19 [10.3%]; OR, 2.54; 95% CI, 1.44-4.51). There were no differences in the proportion of participants between groups with an emergency department visit (65 [30.0%] vs 61 [33.0%]; OR, 0.87; 95% CI, 0.57-1.33) or hospitalization (89 [41.0%] vs 85 [46.0%]; OR, 0.82; 95% CI, 0.55-1.22). Intervention group participants had fewer hospitalizations than control group participants (mean [SD] number of hospitalizations per year, 0.87 [1.60] vs 1.04 [1.77]) and a lower risk of hospitalization (incidence rate ratio, 0.80; 95% CI, 0.65-0.98).Conclusions and RelevanceIn this randomized clinical trial, a multilevel intervention improved oncology clinician–documented ACP compared with a clinician-level intervention alone for patients with genitourinary cancer. The intervention is one approach to effectively increase ACP among patients with cancer.Trial RegistrationClinicalTrials.gov Identifier: NCT03856463

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Section: Discussionsupporting

confidence: 69%

Coaches Activating, Reaching, and Engaging Patients to Engage in Advance Care Planning

Rodriguez,

Parikh,

Kapphahn

et al. 2024

JAMA Oncol

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“…This heterogeneity can impede clinicians from promptly accessing up-to-date directives in emergency situations and result in the loss of ACP-related information during care transitions across health networks. Therefore, there is a clear need for centralized and standardized ACP recording . Standardizing ACP billing codes and incorporating consistent documentation as a crucial benchmark for cancer center accreditation can help achieve this goal.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, there is a clear need for centralized and standardized ACP recording. 20 Standardizing ACP billing codes and incorporating consistent documentation as a crucial benchmark for cancer center accreditation can help achieve this goal. The success of notable systemic ACP interventions supports systematic integration of ACP into specialty care and delivery models.…”

Section: Discussionmentioning

confidence: 99%

“…Patients often lack awareness of these legal documents, avoid discussing death early in the treatment course, and tend to designate ADs during periods of clinical decline . Administrative hurdles to documentation include the lack of standardized systems for reporting and updating ADs . Surgeons may hesitate to facilitate ACP discussions due to time constraints or concerns that AD designation may limit treatment options they consider appropriate .…”

Section: Introductionmentioning

confidence: 99%

“… 17 , 18 , 19 Administrative hurdles to documentation include the lack of standardized systems for reporting and updating ADs. 20 , 21 Surgeons may hesitate to facilitate ACP discussions due to time constraints or concerns that AD designation may limit treatment options they consider appropriate. 16 , 22 , 23 , 24 , 25 Although ACP is associated with less aggressive and less expensive end-of-life care, 5 , 26 health systems bear the cost of developing and delivering ACP interventions.…”

Section: Introductionmentioning

confidence: 99%

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Early Integrated Palliative Care Within a Surgical Oncology Clinic

Bansal,

Kim,

Reddy

et al. 2023

JAMA Netw Open

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ImportanceAdvance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population.ObjectiveTo assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery.Design, Setting, and ParticipantsThis cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023.ExposureIntegration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education.Main Outcomes and MeasuresThe primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation.ResultsAmong the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P &lt; .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P &lt; .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01).Conclusions and RelevanceAn integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.

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Systems for electronic documentation and sharing of advance care planning preferences: a scoping review

Çevik,

Muente,

Muehlensiepen

et al. 2024

Progress in Palliative Care

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Digital approaches to support advance care planning (ACP) documentation and sharing are increasingly being used, with a lack of research to characterise their design, content, and use. This study aimed to characterise how digital approaches are being used to support ACP documentation and sharing internationally. A scoping review was performed in accordance with the JBI (formerly Joanna Briggs Institute) guidelines and the PRISMA 2020 checklist, prospectively registered on Open Science Framework ( https://osf.io/xnrg3 ). MEDLINE, EMBASE, PsycINFO, ACM Digital, IEEE Xplore and CINAHL were searched in February 2023. Only publications in English, published from 2008 onwards were considered. Eligibility criteria included a focus on ACP and electronic systems. Out of 2,393 records, 34 reports were included, predominantly from the USA (76.5%). ACP documentation is typically stored in electronic health records (EHRs) (67.6%), with a third (32.4%) enabling limited patient access. Non-standard approaches ( n = 15;44.1%) were the commonest study design of included reports, with outcome measures focusing on the influence of systems on the documentation (i.e. creation, quantity, quality, frequency or timing) of ACP information ( n = 23;67.6%). Digital approaches to support ACP are being implemented and researched internationally with an evidence base dominated by non-standard study designs. Future research is needed to extend outcome measurement to consider aspects of care quality and explore whether the content of existing systems aligns with aspects of care that are valued by patients.

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Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study

Cited by 6 publications

References 24 publications

Coaches Activating, Reaching, and Engaging Patients to Engage in Advance Care Planning

Coaches Activating, Reaching, and Engaging Patients to Engage in Advance Care Planning

Early Integrated Palliative Care Within a Surgical Oncology Clinic

Systems for electronic documentation and sharing of advance care planning preferences: a scoping review

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