STAMP intervention improves advance care planning among older adults
Click Here to Manage Email Alerts
The Sharing and Talking About My Preferences intervention increased patient participation in advance care planning in ambulatory care settings, according to findings published in the Annals of Internal Medicine.
“Advance care planning is hugely important for many different reasons,” Terri R. Fried, MD, an associate professor of geriatric medicine at the Yale School of Medicine, told Healio Primary Care. “First, it allows individuals to retain control about what happens to them with their health care when they can no longer participate in decision making. Second, it prepares loved ones for what may be the most difficult role they may ever have to take on; namely, making difficult decisions on behalf of the patient. Third, it promotes open communication between patients and their loved ones, which can help them not only prepare for medical decisions but also help to bring closure around other end-of-life issues.”
The Sharing and Talking About My Preferences (STAMP) intervention consisted of an introductory assessment and feedback reports tailored to each patient’s readiness and attitudes regarding advance care planning.
Fried and colleagues conducted a single-blind, cluster randomized controlled trial within 10 pairs of primary and select specialty care practices, including HIV, renal, cardiology and pulmonary. The practices were matched based on patient sociodemographic information. The study evaluated STAMP on its ability to encourage completion of a full range of advance care planning activities among ambulatory care patients after 6 months. STAMP was carried out in person, over the phone or online, depending on patient preference. The study included 909 English-speaking adults aged 55 years or older; 454 were randomly assigned to usual care and 455 were randomly assigned to the intervention. The mean age of patients was 68.3 years; 64.2% were women, 76% were white and 18.4% were Black.
STAMP efficacy
After 6 months, 91% of patients in the intervention group and 95% in the usual care group completed final assessments. The researchers determined that the predicted probability of completing all advance care planning activities in the intervention cohort was 14.1% (95% CI, 11-17.2) compared with 8.2% (95% CI, 4.9-11.4) in the usual care cohort. Among patients who had not completed a living will at baseline, 28.5% (95% CI, 24.5-32.6) in the intervention cohort compared with 20.4% (95% CI, 15-25.7) in the usual care cohort completed one by 6 months. Also, 32.8% (95% CI, 30-35.5) compared with 19.5% (95% CI, 13.3-25.7) had an assigned health care agent and 61.6% (95% CI, 52.6-70.6) compared with 54.4% (95% CI, 46.9-62.1) discussed “quality versus quantity of life” with family members.
Age, education and race did not have a statistically significant impact on the efficacy of the intervention, according to the researchers. Fried said the intervention is feasible to introduce in ambulatory sites before patients develop serious illness.
“The intervention requires a small licensing fee, since it runs on proprietary software. Once the license is obtained, patients can complete assessments on the internet, or a case manager can complete the assessment with the patient on the phone,” she said. “The assessment then generates the feedback report, which can be given to the patient during a visit or mailed to the patient’s home.”
Benefits and limitations
In a related editorial, Susan E. Hickman, PhD, director of the Indiana University Center for Aging Research, and Hillary D. Lum, MD, PhD, an associate professor in the division of geriatric medicine at the University of Colorado Anschutz Medical Center, discussed the benefits and limitations of the STAMP intervention. The results from the study reflect the person-centered process and action advance care planning outcomes, but the intervention does not address other key components of advance care planning like quality of care, health status, health care utilization and surrogate decision-maker preparation, they wrote.
The actual implementation of STAMP is complex and has several challenges, according to Hickman and Lum.
“Using existing staff requires salary support and the potential need to shift a busy workforce’s attention away from another activity,” they wrote. “Implementation also requires access to the computerized tool, a standardized training manual, assessment and monitoring of any risks, on-going fidelity assessments and outcomes tracking in a sustainable way under real-world practice settings.”
Hickman and Lum also noted that the overall effect of STAMP was “modest and did not address pragmatic electronic health record health system outcomes, such as the Advance Care Plan measure defined by the National Quality Forum.”
“This suggests a need for further study or adaptation to ensure that documentation is available and accessible to clinicians,” they wrote.
References:
Fried TR, et al. Ann Intern Med. 2021;doi:10.7326/M21-1007.
Hickman SE, Lum HD. Ann Intern Med. 2021;doi:10.7326/M21-3294.