Empowering Patient Participation in Advance Care Planning Discussions Within Primary Care: The PREPARE Randomized Clinical Trial (TH311A)

Abstract

•Compare the advance care planning (ACP) PREPARE interactive online program with an easy-to-read advance directive and describe their effects on active patient participation in ACP conversations within primary care visits.•Describe the relationship between active patient participation in ACP conversations within primary care visits and completion of ACP documentation. Many factors prevent patients from discussing advance care planning (ACP) in busy outpatient settings. Compare the efficacy of PREPAREforYourCare.org, focused on patient communication training, versus an easy-to-read advance directive (AD) to increase active patient participation in ACP conversations; determine whether participation increases ACP documentation and whether participation explains the previously demonstrated intervention effects on ACP documentation (43% PREPARE vs. 35% AD). We included English and Spanish-speaking primary care patients 55 years of age and older with serious or chronic illness from a VA and public hospital. Patients were randomized to review PREPARE and an easy-to-read AD or the AD alone prior to their visit. Visits were audio-recorded and transcribed. Using a validated coding scheme, coders computed the frequency of active patient participation about ACP (e.g., stating preferences, asking questions). Incident rate ratios (IRR) were calculated comparing active participation between groups and effects of participation on ACP documentation. We assessed whether previously shown intervention effects on ACP documentation were mediated by participation. Among 393 participants, the mean (SD) age was 66 (8.1) years, 31% had limited health literacy, 25.2% were Spanish-speaking, and 43% reported fair-to-poor health. Compared with the AD alone, PREPARE resulted in 41% more active patient participation in ACP discussions during the visit (IRR 1.41, 95% CI=1.00, 1.98, p < .05). Patients with higher active participation had 15% more ACP documentation (IRR 1.15, 95% CI=1.10, 1.20, p<0.001). Active participation explained 16% of the variation in ACP documentation between PREPARE and the AD. PREPARE increased active patient participation in ACP discussions in the outpatient setting more than an AD alone, and participation is associated with increased ACP documentation.