eP822 - Pragmatic Trial of Advance Care Planning Navigators in Surgery for Older Adults and Patients with Serious Illness

ePoster Presenter(s)

• 

  Lindsay Welton, MD (she/her/hers)

  General Surgery Resident
  University of Minnesota
  University of Minnesota
  Minneapolis, MN, United States

  All relevant financial disclosures have been managed and will be listed below.
  This individual has no financial relationships with ineligible companies.

Author(s)

• AC

  Alexis Colley, MD, MS

  University of California San Francisco

  Disclosure information not submitted.
• GM

  Genevieve B. Melton, MD, PhD

  Professor
  University of Minnesota
  Minneapolis, Minnesota, United States

  Disclosure information not submitted.
• 

  Joseph C. Carmichael, MD

  Chief Medical Officer
  UCI Health
  University of California, Irvine
  Orange, CA, United States

  Disclosure information not submitted.
• LP

  Logan Pierce, MD

  Assistant Professor of Medicine
  UCSF Department of Medicine, Division of Hospital Medicine
  San Francisco, California, United States

  Disclosure information not submitted.
• LG

  Lisa Gibbs, MD

  Professor — Department of Family Medicine
  Univeristy of California Irvine
  Irvine, California, United States

  Disclosure information not submitted.
• JK

  Joseph Koopmeiners, MS, PhD

  Mayo Professor and Division Head, Division of Biostatistics & Health Data Science
  Univeristy of Minnesota
  Minneapolis, Minnesota, United States

  Disclosure information not submitted.
• JB

  John Boscardin, PhD

  Professor of Medicine and Epidemiology & Biostatistics
  University of California, San Francisco
  San Francisco, California, United States

  Disclosure information not submitted.
• 

  Joseph Lin, MD

  Fellow
  Cleveland Clinic Foundation, OH
  Cleveland Clinic
  Cleveland, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• RS

  Rebecca Sudore, MD

  Professor of Medicine
  University of California, San Francisco
  San Francisco, California, United States

  Disclosure information not submitted.

Senior Author(s)

• 

  Elizabeth Wick, MD

  Professor
  UCSF
  University of California, San Francisco
  San Francisco, California, United States

  All relevant financial disclosures have been managed and will be listed below.
  This individual has no financial relationships with ineligible companies.

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Purpose/Background: Patients 65 and older account for over 40% of inpatient and 33% of outpatient surgeries annually. For this population, surgery can be a marker of shifting health. Advance care planning (ACP) is the process of understanding and sharing personal values, goals, and preferences for future medical care; surgery may be an opportune time to engage patients in ACP. Real-world, scalable interventions to improve adoption of ACP are lacking particularly in surgery. We hypothesize that the EHR, patient portal tools, nudges via messaging, and patient navigators can be utilized to increase rates of appropriate ACP documentation around surgery.Methods/Interventions: This randomized, controlled, single-blinded, pragmatic trial (funding UG3/UH3 AG081663) integrates a patient/caregiver co-developed ACP letter and a URL to PREPARE™, an evidence-based ACP tool, into the EHR pre-surgery workflow. The population cohort (n=6,000) includes patients 65 and older or with serious illness, who are scheduled for a new surgical visit at UCSF, UCI, or, M Health Fairview, and who have no advance directive (AD) on file within the past 6 months. Participants will be randomized 1:1 in a block design stratified by enrollment site and surgical clinic to arms: (1) Letter, PREPARE™; (2) Letter, PREPARE™, text/phone reminders; (3) Letter, PREPARE™, reminder messages, plus healthcare navigator outreach. All patients will receive a letter via the patient portal that describes ACP and normalizes it as a part of clinical care, and a link to the online PREPARE™ program designed to facilitate AD completion. Automated reminders will be sent via text or phone. The healthcare navigator will introduce ACP, answer basic ACP questions, facilitate the completion and collection of ACP documents, and notify the surgical care teams about obstacles.Results/Outcomes: The primary outcome is clinically meaningful ACP documentation (ACP-specific clinical notes, Smartforms or phrases, advanced directives, Physician Orders for Life Sustaining Treatment, out of hospital do-not-resuscitate order, living wills, ACP problems on problem list, or billing codes) prior to surgery. Secondary outcomes are patient-reported engagement derived from the validated 9-item ACP Engagement Survey. The EHR integrated workflow is currently being piloted at all three sites within colorectal surgery clinics prior to launch of the clinical trial July 2024.Conclusion/

Discussion: The innovation of our trial is four-fold. First, it allows us to assess the effectiveness of a patient-facing tool (PREPARE™) in improving ACP documentation, while testing the comparative effectiveness and acceptability of three increasingly resource intensive delivery models. One-on-one facilitation improves ACP completion; however, it is time-consuming and expensive. Therefore, the relative benefit of each additional level of support between the delivery models is important. Second, the intervention is coordinated via the EHR, ensuring consistent organization of ACP information in an easy-to-use format. Third, our study is across three distinct healthcare systems with varying baseline ACP rates and patient populations. This positions our results to be applicable to diverse healthcare systems. Fourth, set in “real world” surgical practices, with a pioneering pilot study in colorectal clinics, our trial will be exposed to established competing priorities, time constraints, staffing shortages and other limitations which allows our findings to realistically predict potential of widespread successful adoption.Overview of 3-arm pragmatic trial integrating ACP into surgical encounter