Interventions to Improve Advance Care Planning Documentation in the Electronic Health Record : A Cluster Randomized Trial

Anne M Walling¹, Rebecca L Sudore², Lisa Gibbs³, Maryam Rahimi⁴, Ron D Hays⁵, Chi-Hong Tseng⁵, Kanan Patel², Katherine Santos⁵, Fernando Javier Sanz Vidorreta⁶, Aaron J Chau³, Juan Carlos Antonio Lopez⁵, Jamie Anand⁷, G Rick Marshall⁷, Anna DePaolis-Dickey⁵, Kirsten I Buen⁵, Douglas S Bell⁸, Christine S Ritchie⁹, Victor Gonzalez⁵, Neil S Wenger⁵

Affiliations

¹ Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, and VA Greater Los Angeles Health System, Los Angeles, California (A.M.W.).
² Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California (R.L.S., K.P.).
³ Division of Geriatric Medicine and Gerontology, Department of Family Medicine, University of California, Irvine, Irvine, California (L.G., A.J.C.).
⁴ Division of General Internal Medicine & Primary Care, Department of Medicine, University of California, Irvine, Irvine, California (M.R.).
⁵ Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California (R.D.H., C.T., K.S., J.C.A.L., A.D.-D., K.I.B., V.G., N.S.W.).
⁶ Biomedical Informatics Program, UCLA Clinical and Translational Science Institute, University of California, Los Angeles, Los Angeles, California (F.J.S.V.).
⁷ Information Technology Services, University of California, Irvine Health, Irvine, California (J.A., G.R.M.).
⁸ Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, and Biomedical Informatics Program, UCLA Clinical and Translational Science Institute, University of California, Los Angeles, Los Angeles, California (D.S.B.).
⁹ Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, and Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.S.R.).

PMID: 41285010
DOI: 10.7326/ANNALS-25-02111

Interventions to Improve Advance Care Planning Documentation in the Electronic Health Record : A Cluster Randomized Trial

Anne M Walling et al. Ann Intern Med. 2025.

. 2025 Nov 25.

doi: 10.7326/ANNALS-25-02111. Online ahead of print.

Authors

Affiliations

¹ Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, and VA Greater Los Angeles Health System, Los Angeles, California (A.M.W.).
² Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California (R.L.S., K.P.).
³ Division of Geriatric Medicine and Gerontology, Department of Family Medicine, University of California, Irvine, Irvine, California (L.G., A.J.C.).
⁴ Division of General Internal Medicine & Primary Care, Department of Medicine, University of California, Irvine, Irvine, California (M.R.).
⁵ Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California (R.D.H., C.T., K.S., J.C.A.L., A.D.-D., K.I.B., V.G., N.S.W.).
⁶ Biomedical Informatics Program, UCLA Clinical and Translational Science Institute, University of California, Los Angeles, Los Angeles, California (F.J.S.V.).
⁷ Information Technology Services, University of California, Irvine Health, Irvine, California (J.A., G.R.M.).
⁸ Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, and Biomedical Informatics Program, UCLA Clinical and Translational Science Institute, University of California, Los Angeles, Los Angeles, California (D.S.B.).
⁹ Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, and Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.S.R.).

PMID: 41285010
DOI: 10.7326/ANNALS-25-02111

Abstract

Background: Advance care planning (ACP) can improve communication of patients' preferences but is underutilized in health systems.

Objective: To compare approaches to increase ACP.

Design: Pragmatic, 24-month, comparative, cluster randomized trial. (ClinicalTrials.gov: NCT04012749).

Setting: Fifty clinics in 3 University of California health systems.

Participants: All seriously ill primary care patients without an advance directive (AD) or a Physician Orders for Life-Sustaining Treatment (POLST) form in the electronic health record (EHR).

Intervention: Three ACP interventions, timed to primary care visits. The group 1 intervention included a letter with an AD sent via the EHR portal and mail. The interventions in groups 2 and 3 additionally included a link to PrepareForYourCare.org and a mailed pamphlet, and the group 3 intervention also included health navigator outreach. Clinicians received ACP training.

Measurements: Presence of AD or POLST form in the EHR at 12 and 24 months (primary outcome); documented ACP discussions and utilization (secondary outcomes).

Results: Among 5810 seriously ill patients (mean age, 71 years; 48% female; 50% in a racial or ethnic minority), by 24 months, 13.7% (95% CI, 12.1% to 15.3%) of patients in group 1, 12.7% (CI, 11.2% to 14.1%) in group 2, and 19.8% (CI, 18.1% to 21.5%) in group 3 had a documented AD or POLST form. After adjustment for patient and site factors, group 3 patients were more likely to have an AD or a POLST form compared with group 1 (adjusted difference [aDiff], 4.6% [CI, 0.8% to 8.4%]) and group 2 (aDiff, 5.5% [CI, 0.8% to 10.2%]); groups 1 and 2 did not differ significantly. Documented ACP discussions were higher in group 3 than group 1 (aDiff, 4.7% [CI, 1.4% to 7.9%]) and group 2 (aDiff, 4.2% [CI, 1.1% to 7.2%]); groups 1 and 2 did not differ. Utilization did not differ by group.

Limitations: Academic health centers; no control group.

Conclusion: Health system implementation of automated ACP interventions with clinician training and mailed materials increases ACP documentation and is enhanced with navigator outreach.

Primary funding source: Patient-Centered Outcomes Research Institute.

PubMed Disclaimer

Conflict of interest statement

Disclosures: Disclosure forms are available with the article online.

Associated data

Actions
- Search in PubMed
- Search in ClinicalTrials.gov

LinkOut - more resources

Full Text Sources
- Atypon

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Interventions to Improve Advance Care Planning Documentation in the Electronic Health Record : A Cluster Randomized Trial

Affiliations

Interventions to Improve Advance Care Planning Documentation in the Electronic Health Record : A Cluster Randomized Trial

Authors

Affiliations

Abstract

Conflict of interest statement

Associated data

LinkOut - more resources

Full Text Sources