Abstract
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. 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. 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. The primary outcome was ACP documentation. 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). This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients. ClinicalTrials.gov Identifier: NCT04660422.
Highlights
The COVID-19 pandemic has resulted in more than 800 000 deaths in the US, 77% of which were among people 65 years or older and 33% among African American and Hispanic individuals.[1]
Clinicians documented advance care planning (ACP) in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre–COVID-19 period 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)
Summary
The COVID-19 pandemic has resulted in more than 800 000 deaths in the US, 77% of which were among people 65 years or older and 33% among African American and Hispanic individuals.[1] Many of these patients faced emergency decisions about the use of life-sustaining treatments, an eventuality for which they and their families were often unprepared.[2] Advance care planning (ACP) seeks to help patients receive care that reflects what matters most to them.[3] This process anchors on educating patients about the medical care they may receive and elucidating their informed preferences through iterative conversations and discussions.[3,4] In addition, ACP often includes choosing and preparing another trusted person to make medical decisions in the event that an individual no longer can do so themselves.[3,4,5] In normal times, such advance decision-making may seem hypothetical for many people who cannot imagine future health states.[6] the COVID-19 pandemic has presented a unique ACP context, especially for elderly, African American, and Hispanic patients for whom the pandemic has made such choices a familiar reality.[7] Advance care planning is no longer hypothetical. Many clinicians working during the pandemic are intimately familiar with the dire situations that arise and hope to ease the burden of decision-making on patients and families
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