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.

项目概要 近 2000 万老年人接受重大选择性外科手术，但很少有人接受预先护理 这是一个重要的错失机会，无法确保最佳且符合患者的医疗决策和目标。 尽管 ACP 已纳入国家质量指标和社会外科指南中。 对于老年人的护理，迄今为止，有效融入术前阶段的例子很少。 主要关注于改善外科医生对 ACP 的使用，但障碍仍然很大，包括不同程度的障碍 进行 ACP 对话的熟悉度和舒适度，在术前护理期间缺乏专门时间 这些通常是微妙的对话的情节，并且缺乏适当的面向患者的 ACP 工具来帮助患者 和护理人员对其手术治疗做出复杂的决定我们的团队设计并测试了一个。 基于理论的交互式 ACP 面向患者的技术解决方案 (PREPARE) 基于新的 ACP 范式 尽管有一致的证据表明，人们为沟通和医疗决策做好准备。 PREPARE 增加了 ACP 参与度以及患者和临床医生讨论 ACP 的权力，但仍存在差距 在将 PREPARE 的用途扩展到手术前人群时，我们通过将 PREPARE 纳入其中来抓住这一点。 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， 鉴于时间和时间有限，我们可以授权患者和手术团队参与 ACP 讨论。 为了进行 ACP，我们将测试 3 种实施策略以增加资源 强度（单独准备、通过短信/电话提醒或附加医疗导航器进行准备）。 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：加州大学、旧金山分校。 (UCSF)、加州大学欧文分校 (UCI) 和 M Health Fairview (UMN，明尼苏达大学医学院的合作项目) 学校、明尼苏达大学医师学院和 Fairview Health Services）我们将首先建立试验基础设施 (UG3)。 对 3 名 65 岁或以上的 HCS 患者进行 (UH3) NIH III 期模型（功效-效果）三臂随机对照试验。 年龄较大或患有严重疾病且被转诊进行重大择期手术的人将被随机分配到组：(1) 字母 关于 ACP、PREPARE 高级指令 (AD)、PREPARE 网站 (2) 信件、AD、PREPARE 加提醒； 短信/电话消息；(3) 信函、AD、PREPARE 以及提醒以及 ACP 上的医疗导航器 文档（讨论和护理计划、主要结果）和患者报告的 ACP 参与情况。 混合方法，我们将评估患者和手术护理团队对 ACP 手术记录的经验。 将使用自然语言处理 (NLP) 和数据挖掘来评估内容，以开始识别评估 ACP 笔记的主题完整性这项工作具有创新性，因为我们正在合并现有的合作。 将 HCS 纳入一个由外科医生、老年病学家和信息学家组成的跨学科小组，涵盖三个健康领域 系统将开发基础设施并严格测试以患者为中心的新型系统级方法 将 ACP 纳入手术护理过程中，这是实现目标一致的手术护理的第一步。