Improving advanced care planning for late-stage cancer

Multilevel care interventions improved clinician–documented advanced care planning (ACP) compared with a clinician-level intervention alone for patients with genitourinary cancer, according to findings published in JAMA Oncology.

"Clinicians often have limited time to assist patients in fully understanding ACP. This intervention is one approach to improve ACP and care delivery among patients with advanced stages of genitourinary cancer," said Gladys M. Rodriguez, MD, MS, assistant professor of Medicine in the Division of Hematology and Oncology and lead author of the study.

For patients diagnosed with late-stage cancer, ACP can help reduce unnecessary acute care, increase palliative care and improve quality of life. However, previous reports have found that less than 20% of patients will engage in ACP with their health care providers.

This extremely low participation, according to Rodriguez, can be attributed to multiple factors, including limited ACP training for clinicians, challenges with documenting ACP discussions in patients' electronic health records, and limited interventions that help patients understand and engage in ACP with their health care team.

In the current study, Rodriguez and colleagues aimed to determine whether a multi-level ACP intervention could improve clinician-documented ACP more than a clinician-level ACP intervention alone.

More than 400 adults with advanced genitourinary cancers from a single academic medical center were randomized to undergo a six-month educational program about ACP delivered by a lay health worker along with a clinician-level intervention composed of three-hour ACP training and integration of a structured electronic health record documentation template (intervention group) or to a clinical-level intervention alone (control group).

The primary outcome was ACP documentation in the electronic health record by the patient's oncology clinician within 12 months. Secondary outcomes included shared decision-making, palliative care use, hospice use, emergency department visits and hospitalizations within 12 months.

At the 12-month follow-up, the multilevel intervention was more effective in improving ACP documentation compared to the clinician-level intervention alone; 38% versus 22%, respectively. The multilevel intervention also improved shared decision making, doubled the odds of palliative care and hospice referrals, and reduced hospitalization rates by 20%, compared to the clinician-level intervention alone.

Going forward, Rodriguez said her team aims to evaluate the intervention in racial and ethnic minority patient groups.

"ACP discussions and documentation is lower in racial and ethnic minority groups compared to non-Hispanic white individuals. We hope to evaluate this intervention with a more diverse patient population in different types of advanced cancers," said Rodriguez, who is also a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.