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Promoting advance directives among elderly primary care patients

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Abstract

OBJECTIVE: To determine efficient ways of promoting advance directives among heterogeneous populations of elderly ambulatory patients.

DESIGN: One-year quasi-experimental trial.

SETTING: Five suburban and urban health centers in one region of a large managed care organization. One additional suburban center served as a control site.

PARTICIPANTS: Individuals ages 65 and older (N=2,120) who were continuously enrolled and had a health maintenance visit with their primary care provider during the study year.

INTERVENTION: Physician education (oral and written) and physician and patient prompts to discuss advance directives.

MAIN RESULTS: Sixty-six (7.8%) of patients at the intervention centers completed new advance directives, versus 9 of 1,277 (<1%) at the comparison center (P<.001). Patients 75 and older were twice as likely (odds ratio [OR], 2.0; 95% confidence limits [CL], 1.2 to 3.3) as those 65 to 74 to file a new advance directive, and the odds were twice as great (OR, 2.6; 95% CL, 1.4 to 4.6) at centers serving communities with median household income over the state median. Gender, recent hospitalization, emergency room visits, and number of chronic conditions were not related to making new directives nor was predominant ethnicity of the center community (African-American versus white). Adjusted for these factors, the intervention resulted in a 20-fold increase (95% CL, 10.4 to 47.8) in the odds of creating a new advance directive. Doctors reported barriers of time and unwillingness to press discussions with patients.

CONCLUSIONS: A replicable intervention largely targeting doctors achieved a modest increase in advance directives among elderly ambulatory patients. Future interventions may need to target lower-income patients, “younger” elderly, and more specifically address doctors’ attitudes and comfort discussing advance directives.

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Authors and Affiliations

  1. the Johns Hopkins Bloomberg School of Public Health, Baltimore, Md

    Lawrence S. Wissow MD, MPH, Amy Belote MHS & Jonathan P. Weiner DrPH

  2. Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., Rockville, Md

    Wade Kramer BS, MPH

  3. Mid-Atlantic Permanente Medical Group, Baltimore, Md

    Amy Compton-Phillips MD & Robert Kritzler MD

  4. the Bioethics Institute, Johns Hopkins University, Baltimore, Md

    Lawrence S. Wissow MD, MPH

Authors
  1. Lawrence S. Wissow MD, MPH
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  2. Amy Belote MHS
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  3. Wade Kramer BS, MPH
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  4. Amy Compton-Phillips MD
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  5. Robert Kritzler MD
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  6. Jonathan P. Weiner DrPH
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Corresponding author

Correspondence to Lawrence S. Wissow MD, MPH.

Additional information

This investigation was supported in part by a grant from the Pew Charitable Trusts.

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Wissow, L.S., Belote, A., Kramer, W. et al. Promoting advance directives among elderly primary care patients. J GEN INTERN MED 19, 944–951 (2004). https://doi.org/10.1111/j.1525-1497.2004.30117.x

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  • DOI: https://doi.org/10.1111/j.1525-1497.2004.30117.x

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