Trial Summary

Nearly 20 million older adults undergo major elective surgical procedures, yet very few receive advance care planning (ACP). This is a critical missed opportunity to ensure optimal and patient-aligned medical decisions and communications. Despite ACP being incorporated into national quality metrics and society guidelines for surgical care for older adults, there are few examples of effective integration into the pre-surgical phase. Efforts to date have mostly focused on improving surgeons’ use of ACP but barriers remain significant, including varying levels of familiarity and comfort to conduct ACP conversations, lack of dedicated time during the pre-surgical care episode for these often-delicate conversations, and lack of appropriate patient-facing ACP tools to help patients and caregivers make complex decisions about their surgical treatment. Our team has designed and tested a theory-based, interactive ACP patient-facing technology solution (PREPARE) based on the new ACP paradigm of preparing people for communication and medical decision-making. Despite consistent evidence that PREPARE increases ACP engagement and patient and clinician empowerment to discuss ACP, a gap remains in extending PREPARE’s use to pre-surgical populations. We hypothesize that by including PREPARE into the electronic health record (HER)-centric pre-surgery workflow for older adults and including automated reminders, we can empower patients and surgical teams to engage in ACP discussions. Given the limited time and resources in the surgical setting to conduct ACP, we will be testing 3 delivery strategies in increasing resource intensity (PREPARE alone, PREPARE with text/phone reminders, or the additional of a healthcare navigator). To ensure generalizability, we will conduct our work in 3 healthcare systems (HCS): Univ. of CA, San Francisco (UCSF), Univ. of CA, Irvine (UCI) and M Health Fairview (UMN, a collaboration among the Univ. of MN Medical School, Univ of MN Physicians, and Fairview Health Services). We will first establish trial infrastructure (UG3) to conduct (UH3) an NIH Stage Model III (efficacy-effectiveness) three arm RCT in 3 HCS. Patients aged 65 or older, or with serious illness, who are referred for major elective surgery will be randomized to Arms: (1) Letter about ACP, PREPARE advanced directive (AD), PREPARE website; (2) Letter, AD, PREPARE plus reminder text/phone messages; (3) Letter, AD, PREPARE plus reminders plus a healthcare navigator on ACP documentation (discussions and care plans, primary outcome) and patient-reported ACP engagement. Using mixed methods, we will assess patients’ and surgical care teams' experience with surgery ACP. ACP note content will be evaluated using natural language processing (NLP) and data mining to begin to identify assess thematic completeness of ACP notes. This work is innovative because we are coalescing existing collaborations between HCS into a transdisciplinary group of surgeons, geriatricians, and informaticians to develop infrastructure and rigorously test a novel patient-centered system-level approach to integrating ACP into the surgical care episode, the first step towards goal-concordant surgical care.

NIH Project Information