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

I CAN DO Surgical ACP（提高外科高级护理计划的完成度、准确性和传播）试验

• 批准号: 10649843
• 负责人: Genevieve B Melton-Meaux
• 金额: $ 69.88万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-08-01 至 2024-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10649843
• 关键词: Adoption; Advance Care Planning; Advance Directives; Articulation; Biometry; Caregivers; Caring; Cessation of life; Clinic; Clinical; Clinical Trials; Collaborations; Colonoscopy; Communication; Complex; Data Science; Decision Making; Dedications; Documentation; Effectiveness; Elderly; Elective Surgical Procedures; Electronic Health Record; Ensure; Evaluation; Familiarity; Foundations; Geography; Geriatrics; Goals; Guidelines; Health; Health Services; Health Status; Health behavior; Health system; Healthcare; Healthcare Systems; Home; Human; Impairment; Individual; Informatics; Infrastructure; Intervention; Letters; Mammography; Measures; Medical; Methods; Modality; Modeling; Natural Language Processing; Operative Surgical Procedures; Outcome; Outcome Measure; Patient Care Planning; Patients; Persons; Phase; Physicians; Population; Preparation; Randomized; Randomized, Controlled Trials; Reporting; Research; Resources; San Francisco; Societies; Surgeon; Surveys; System; Technology; Telephone; Testing; Text; Time; Training; United States Centers for Medicare and Medicaid Services; United States National Institutes of Health; Work; aged; arm; care episode; data mining; design; digital intervention; digital tool; effectiveness evaluation; empowerment; end of life; evidence base; experience; functional disability; handheld mobile device; implementation science; improved; innovation; medical schools; novel; patient engagement; patient oriented; patient portal; pilot test; preference; primary outcome; programs; remote health care; surrogate decision maker; theories; tool; virtual healthcare; web site

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.

项目摘要 近2000万老年人接受了主要的择期手术，但很少有人得到提前护理 规划(机场核心计划)。这是一个严重错失的机会，无法确保最佳和与患者一致的医疗决策和 通讯。尽管ACP被纳入国家外科质量标准和学会指南 在对老年人的护理方面，有效地融入手术前阶段的例子很少。迄今为止的努力 主要集中在改善外科医生对ACP的使用上，但障碍仍然很大，包括水平不一 熟悉和舒适地进行ACP对话，在术前护理期间缺乏专门的时间 对于这些经常微妙的对话，以及缺乏适当的面向患者的ACP工具来帮助患者 护理者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一种 基于新的ACP范例的基于理论的交互式ACP面向患者的技术解决方案(准备) 为人们的沟通和医疗决策做好准备。尽管有一致的证据表明 Prepare增加了ACP的参与度，并增强了患者和临床医生讨论ACP的能力，但仍存在差距 将Prepare的使用推广到手术前人群。我们假设通过将Prepare包含在 以电子健康记录(HER)为中心的老年人手术前工作流程，包括自动提醒， 我们可以让患者和手术团队参与到非加太计划的讨论中。鉴于时间有限，而且 在外科环境下进行ACP的资源，我们将测试3种交付策略以增加资源 强度(单独准备，通过短信/电话提醒准备，或额外配备医疗导航器)。 为了确保普适性，我们将在3个医疗保健系统(HCS)中开展工作：Univ.加利福尼亚州，旧金山 (加州大学旧金山分校)，大学。加州大学、欧文大学(UCI)和M Health Fairview(UMN)，这是大学之间的合作MN医疗集团的 学校、明尼苏达州医科大学和美景卫生服务)。我们将首先建立试验基础设施(UG3)以 在3个HCS中进行(UH3)NIH阶段模式III(疗效-有效性)三臂随机对照试验。65岁或以上的病人 年龄较大或患有严重疾病，被转介进行重大择期手术的人将被随机分配到ARM：(1)信 关于ACP，准备高级指令(AD)，准备网站；(2)信函，AD，准备加提醒 短信/电话信息；(3)信函、广告、准备和提醒以及ACP上的医疗导航器 记录(讨论和护理计划、主要结果)和患者报告的ACP参与度。vbl.使用 混合方法，我们将评估患者和外科护理团队在手术ACP方面的经验。ACP备注 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 非加太项目说明的主题完整性。这项工作是创新的，因为我们正在合并现有的合作 在HCS之间形成一个由外科医生、老年病医生和信息专家组成的跨学科小组，涵盖三个健康领域 将开发基础设施并严格测试以患者为中心的系统级新方法的系统 将ACP整合到外科护理中，是迈向与目标一致的外科护理的第一步。