Marcia Frellick

May 19, 2017

SAN ANTONIO — A simple website that walks users through a five-step process to answer questions about advance care planning led to a significant increase in documentation in their electronic health records, results from the PREPARE study (NCT01550731) show.

"We didn't want to just tell people how to do something, we wanted to show them how to do something," said Rebecca Sudore, MD, a geriatrician and palliative care specialist at University of California, San Francisco, who is one of the developers of the website.

Users of the PREPARE website are asked questions such as "What is most important to you?" and "What does quality of life mean to you?" This can spark a person to have conversations with family, friends, and physicians, Dr Sudore told Medscape Medical News.

The language used on the website is at a fifth-grade level, and the text presented is large and is accompanied by an audio track for people with visual or hearing impairments. Videos depict different elements of advance care planning, such as one person asking another to be a medical decision maker. The website is available in English and Spanish.

For their study, Dr Sudore and her colleagues assessed participants from multiple clinics associated with the San Francisco Veterans Administration Medical Center.

Study results were presented here at the American Geriatrics Society 2017 Annual Scientific Meeting and published online simultaneously.

All 414 participants reviewed an easy-to-read advance directive booklet, which is available free on the PREPARE website. In addition, 205 participants were randomly assigned to review the website.

Participants viewed the tools in the research offices as they would around their own kitchen table, Dr Sudore explained. No clinician or system-level support was necessary.

Mean age in the study cohort was 71 years, 43% of the participants were nonwhite, 20% had limited literacy, and 9% were women. Demographic characteristics were similar in the website and the booklet-only groups.

The primary end point of the study was new documentation — either an advance directive or a documented conversation about advance planning — in the patient's electronic health record. This end point requires a patient to engage enough to spur a physician to document the information, Dr Sudore pointed out.

In the 6 months before the intervention, fewer than 1% of participants had advance planning information added to their electronic health records.

Nine months after the intervention, this rate increased in both groups, but was significantly higher in the website group than in the booklet-only group (35% vs 25%; P = .04).

In fact, the rate of documentation was 61% higher in the website group than in the booklet-only group (odds ratio,1.61; 95% confidence interval, 1.03 - 2.51).

The increase from baseline in self-reported engagement over time — assessed with a validated engagement survey that measured confidence, engagement, preparedness, and actions such as discussions with family and friends — was significantly greater in the website group than in the booklet-only group (P < .001).

Barriers to advance care planning — specifically, physician time and lack of healthcare resources — can be overcome with this intervention because it is designed to help patients directly, Dr Sudore said.

"PREPARE and the easy-to-read advance directive booklet may be useful interventions on a population level," she added, "especially in resource-poor health systems."

Libraries should know about this website, said Kimberly Hickey, a geriatrics clinical nurse specialist at University of Michigan in Ann Arbor, who acknowledged that she had not heard of it until this presentation.

"Libraries thrive on new programs, and they love to give information to the population they serve," said Hickey, who has been a trustee of the library board in Plymouth, Michigan, for 20 years.

"The American Library Association would jump on something like this," she added.

Just as libraries have supplied computers and provided support to help people apply for jobs, libraries would be a great place for older people to access advance planning information.

Dr Sudore discussed the PREPARE study on a recent podcast, which can be found on the GeriPal website.

The study was funded by the US Department of Veterans Affairs. Dr Sudore has disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2017 Annual Scientific Meeting. Presented May 18, 2017.

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