The PREPARE for Your Care program increases advance care planning engagement among diverse older adults with cancer

Abstract

Background: Advance care planning (ACP) is low among older adults with cancer. In a secondary analysis of randomized trial data, the authors compared the efficacy of the PREPARE for Your Care (PREPARE) website plus an easy-to-read advance directive (AD) with an AD only among older adults with and without cancer.

Methods: Safety net, primary care patients in San Francisco were included if they were 55 years old or older, were English- or Spanish-speaking, and had 2 or more chronic conditions. The authors determined cancer diagnoses by using International Classification of Diseases, Ninth Revision/Tenth Revision codes. The primary outcome was new ACP documentation in the medical record at 15 months; the secondary outcomes were self-reported ACP engagement, ease of use, satisfaction, and depression/anxiety. The authors used mixed effects logistic and linear regression adjusted for prior ACP, health literacy, and clinician, including a cancer interaction term.

Results: Of 986 participants, 220 (22%) had cancer. The mean age was 63 years (SD, 6 years), 61% were women, 81% were of a minority race/ethnicity, 45% were Spanish-speaking, 39% had limited health literacy, and 27% had prior ACP. New ACP documentation was higher in the PREPARE arm versus the AD-only arm among participants with cancer (62% vs 43%; P = .01) and without cancer (38% vs 28%; P = .01), as was ACP engagement in both arms (P < .001), with no interactions by cancer. Ease of use and satisfaction were high, and depression/anxiety was low, with no differences by study arm or by cancer/no cancer.

Conclusions: PREPARE plus an easy-to-read AD increased ACP documentation and engagement among diverse older adults with cancer more than an AD alone, with no increase in depression or anxiety between study arms or by cancer. PREPARE may help to decrease ACP disparities among patients with cancer.

Lay summary: Advance care planning (ACP) is the process of sharing values, goals, and preferences for medical care, but engagement in ACP is low among older adults with cancer. Among 986 English- and Spanish-speaking older adults from a safety net hospital, an interactive, multimedia, web-based ACP program (PREPARE for Your Care at https://prepareforyourcare.org/) plus an easy-to-read advance directive increased ACP documentation and engagement more than an advance directive alone. There were no differences in this increase in ACP between older adults with cancer and older adults without cancer. Also, engaging in ACP did not result in increased depression or anxiety.

Keywords: advance care planning; health care disparities; safety net providers; vulnerable populations.

Figure 1.. New Advance Care Planning (ACP) Documentation in the Medical Record at 15 months.^a

^a Mixed effects logistic regression model adjusted for baseline documentation of ACP and health literacy, clustered by clinician, and stratified by cancer group.

Figure 2.. Advance Care Planning (ACP) Engagement Behavior Change Process and Action Scores.^a

A. Behavior change scores in participants with cancer. B. Behavior change scores in participants without cancer. C. Action scores in participants with cancer. D. Action scores in participants without cancer. ^a Mixed effects linear regression models adjusted for baseline documentation of ACP and health literacy, clustered by clinician, and stratified by cancer group. Behavior change process scores (e.g., self-efficacy and readiness) were measured on a 5-point Likert scale and action scores (e.g., reported goals of care discussion) on a 0-25 scale.