Clinical Decision Support Technology to Increase Advance Care Planning in the Primary Care Setting

Abstract

Physicians are often unable to guide patients through the advance care planning (ACP) process due to cost and time constraints. We conducted a retrospective analysis in the primary care setting targeting older adults without an advance medical directive (AMD). An ACP educational packet was sent to intervention patients before their health maintenance examination (HME). Additionally, their physicians had access to a computerized clinical decision support system on AMD completion at the time of the HME. Control participants’ physicians had access to the computerized decision support system and traditional resources only. All participants who received the packet were sent a follow-up survey. In all, 21.6% of intervention participants completed an AMD, compared with 4.1% of control participants. Combining clinical decision support systems and standardized processes enhances the ACP process.

Keywords

advance care planning electronic decision support patient education primary care advance medical directive barriers

References

Hare J. , Nelson C. Will outpatients complete living wills? A comparison of two interventions . J Gen Intern Med. 1991; 6(1):41-46.

Tierney WM , Dexter PR , Gramelspacher GP , Perkins AJ , Zhou XH , Wolinsky FD The effect of discussions about advance directives on patients’ satisfaction with primary care. J Gen Intern Med. 2001;16(1):32-40.

Ramsaroop SD , Reid MC , Adelman RD Completing advance directive in the primary care setting: what do we need for success. J Am Geriatr Soc . 2007;55(2):277-283.

Landry FJ , Kroenke K. , Lucas C. , Reeder J. Increasing the use of advance directives in medical outpatients. J Gen Intern Med. 1997;12(7):412-415.

Pearlman RA , Starks H. , Cain KC , Cole WG Improvements in advance care planning in the Veterans Affairs System: results of a multifaceted intervention. Arch Intern Med. 2005;165(6): 667-674.

Wissow LS , Belote A. , Kramer W. , Compton-Phillips A. , Kritzler R. , Weiner JP Promoting advance directives among elderly primary care patients. J Gen Intern Med. 2004;19(9): 944-951.

Brown JB , Beck A. , Boles M. , Barrett P. Practical methods to increase use of advance medical directives. J Gen Intern Med. 1999;14(1):21-26.

Dexter PR , Wolinsky FD , Gramelspacher GP , et al. Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms . Ann Intern Med. 1998;128(2):102-110.

Zanaboni P. , Scalvini S. , Bernocchi P. , Borghi G. , Tridico C. , Masella C. Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness. BMC Health Serv Res. 2009;9:238.

10.

Balas EA , Weingarten S. , Garb CT , Blumenthal D. , Boren SA , Brown GD Improving preventive care by prompting physicians. Arch Intern Med. 2000;160(3):301-308.

11.

Yarnall KS , Pollak KI , stbye T. , Krause KM , Michener JL

Primary care: is there enough time for prevention?

Am J Public Health. 2003;93(4):635-641.

12.

Yarnall KS , stbye T. , Krause KM , Pollak KI , Gradison M. , Michener JL Family physicians as team leaders: ‘‘time’’ to share the care. Prev Chronic Dis. 2009;6(2):A59.

13.

Crabtree BF , Miller WL , Tallia AF , et al. Delivery of clinical preventive services in family medicine offices. Ann Fam Med. 2005 ; 3(5):430-435.

14.

Grumbach K. , Bodenheimer T.

Can health care teams improve primary care practice?

JAMA. 2004;291(10):1246-1251.

15.

Tung E. , North F. Advance care planning in the primary care setting: a comparison of attending staff and resident barriers. Am J Hosp Palliat Med. 2009;26(6):456-463.

16.

Sulmsasy DP , Song KY , Marx ES , Mitchell JM Strategies to promote the use of advance directives in a residency outpatient practice. J Gen Intern Med. 1996;11(11):657-663.

17.

Meier DE , Gold G. , Mertz K. , et al. Enhancement of proxy appointment for older persons: physician counseling in the ambulatory setting. J Am Geriatr Soc. 1996;44(1):37-43.

18.

Heiman H. , Bates DW , Fairchild D. , Shaykevich S. , Lehmann LS Improving completion of advance directives in the primary care setting: a randomized controlled trial. Am J Med. 2004 ;117(5): 318-324.

19.

20.

Rubin SM , Strull WM , Fialkow MF , Weiss SJ , Lo B. Increasing the completion of the durable power of attorney for health care . A randomized, controlled trial. JAMA. 1994 ;271(3):209-212.

21.

Fried TR , Bullock K. , Iannone L. , O’Leary JR Understanding advance care planning as a process of health behavior change . J Am Geriatr Soc. 2009;57(9):1547-1555.

22.

Sachs GA , Stocking CB , Miles SH Empowerment of the older patient? A randomized controlled trial to increase discussion and use of advance directives. J Am Geriatr Soc . 1992;40(3):269-273.

23.

Luptak M. , Boult C. A method for increasing elders’ use of advance directives. Gerontologist. 1994;34(3):409-412.

24.

Kross EK , Engelberg RA , Shannon SE , Curtis JR Potential for response bias in family surveys about end-of-life care in the ICU. Chest. 2009;136(6):1496-1502.