With the onset of the COVID-19 pandemic, the need for advance care planning (ACP) stopped seeming hypothetical to many patients, especially older, Black and Latino/a/x patients.
Charlotta J. Lindvall, MD, PhD, a physician in the Division of Palliative Medicine at Brigham and Women’s Hospital, James A. Tulsky, MD, chief of the division, and colleagues recognized an opportunity. In a large, diverse population of older outpatients, they tested an ACP intervention that integrated video decision aids and remote clinician training. As reported in JAMA Network Open, the intervention significantly improved the rate of ACP documentation overall and in the Black and Latino/a/x subgroups.
The Cohort and Study Periods
The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions (ACP-COVID) study was a pre/post, open-cohort nonrandomized controlled trial. Three six-month periods were prespecified for comparing ACP documentation:
- Pre–COVID-19: September 15, 2019, to March 14, 2020 (n=14,107; 16% Black or Latino/a/x)
- Wave 1: March 15 to September 14, 2020 (n=12,806; 16% Black or Latino/a/x)
- Intervention period: December 15, 2020, to June 14, 2021 (n=15,106; 17% Black or Latino/a/x)
Patient sociodemographics were similar across the study periods.
The Interventions
For patients—The study subjects were all patients ≥65 years old who had at least one in-person or telehealth visit to a participating outpatient clinic during any of the three periods. During the intervention period, patients received links to four video decision aids before the appointment: Choosing a Health Care Proxy, Having an ACP Conversation, What Is COVID-19, and COVID-19 Vaccinations.
Videos were available in English or Spanish, designed for a health literacy level of less than sixth grade. Images of patients and clinicians reflected the community being served. Clinic-level data on video use were monitored weekly, and dissemination efforts (texting, email, or mailings) were modulated accordingly.
For clinicians—All clinicians affiliated with participating clinics were offered communications skills training. In a four-hour VitalTalk-designed interactive training via Zoom, clinicians practiced introducing the concept of ACP, discussing prognosis, exploring cultural concerns unique to racial/ethnic minority communities, and addressing common COVID-19 ACP scenarios.
Video Use
Video use was robust:
- 5,302 videos were viewed during the intervention period
- 68% of videos watched were related to ACP and 32% to COVID-19
- For 90% of videos viewed, patients watched ≥50% of the content
Clinician Training
Of 219 clinicians eligible, 85% participated in communication training.
Primary Outcome
The primary outcome was documentation of ACP in a clinician’s electronic health record note. Human-assisted natural language processing was used to detect discussions about goals of care and preferences for future medical care, palliative care, hospice, or a healthcare proxy.
Documentation of ACP was greatest during the intervention period:
- Pre–COVID-19: 18% of all patients; 17% of Black and Latino/a/x patients
- Wave 1: 13% and 11%
- Intervention period: 24% and 26%; both figures were significantly higher than for the two other periods
Implications for Multiple Stakeholders
For three decades, widespread use of ACP has been an elusive goal for most healthcare systems. The ACP-COVID trial improved ACP documentation rapidly and efficiently, and the intervention could be quickly implemented nationally.
Patients, caregivers, and clinicians deserve to have rapidly changing information disseminated in a meaningful way and in a fashion that honors and respects the diverse communities affected. Healthcare systems, corporate leaders, and government officials will be heartened to learn that the ACP-COVID intervention is a readily adoptable program with a significant ability to promote ACP, a widely used quality metric.