I CAN DO Surgical ACP (Improving Completion, Accuracy, and Dissemination Of Surgical Advanced Care Planning) Trial

项目摘要 近2000万老年人接受重大的择期外科手术，但很少有人得到预先护理 （ACP）。这是一个关键的错失机会，以确保最佳和患者一致的医疗决策， 通讯尽管ACP已被纳入国家质量指标和社会指南， 在老年人的护理方面，很少有有效融入手术前阶段的例子。迄今所作的努力 主要集中在改善外科医生对ACP的使用，但障碍仍然很大，包括不同程度的 进行ACP对话的熟悉度和舒适度，术前护理期间缺乏专门的时间 这些通常微妙的对话的插曲，以及缺乏适当的面向患者的ACP工具来帮助患者 护理人员对他们的手术治疗做出复杂的决定。我们的团队设计并测试了 基于新ACP范式的基于理论的交互式ACP面向患者的技术解决方案（ACTE） 帮助人们进行沟通和医疗决策。尽管有一致的证据表明， ACEE增加了ACP参与度，并增强了患者和临床医生讨论ACP的能力，但仍存在差距 在手术前人群中推广使用我们假设，通过将BAE纳入 针对老年人的以电子健康记录（HER）为中心的术前工作流程，包括自动提醒， 我们可以让患者和手术团队参与ACP讨论。鉴于时间有限， 在外科环境中进行ACP的资源，我们将测试3种输送策略以增加资源 强度（单独使用电子病历、使用文本/电话提醒的电子病历或额外的医疗保健导航）。 为了确保普遍性，我们将在3个医疗保健系统（HCS）中开展工作：加利福尼亚大学，旧金山弗朗西斯科 （UCSF），加州大学欧文分校（UCI）和M Health Fairview（UMN，MN医学大学之间的合作 学校，明尼苏达大学医师和费尔维尤健康服务）。我们将首先建立试验基础设施（UG 3）， 在3例HCS中进行（UH 3）NIH阶段模型III（疗效-有效性）三组RCT。65岁或 年龄较大或患有严重疾病的患者将被随机分配至以下组：（1）字母 关于ACP、AEE高级指令（AD）、AEE网站;（2）信函、AD、AEE加提醒 文本/电话信息;（3）信件、广告、电子邮件和提醒以及ACP上的医疗导航器 记录（讨论和护理计划，主要结局）和患者报告的ACP参与。使用 混合方法，我们将评估患者和手术护理团队的经验与手术ACP。非加太集团说明 内容将使用自然语言处理（NLP）和数据挖掘进行评估，以开始识别和评估 非加太集团说明的主题完整性。这项工作是创新的，因为我们正在合并现有的合作 HCS之间的跨学科小组的外科医生，老年病学家，和信息学家在三个健康 这些系统将开发基础设施，并严格测试一种新的以患者为中心的系统级方法， 将ACP整合到外科护理事件中，这是实现目标一致的外科护理的第一步。

Project 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 across three health systems that will 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.