The Program for the Study of Health Care Relationships funded 11 researchers in CT to study various aspects of health care relationships and adherence. The individuals listed below each received grants for one year (2001-02). They were awarded funds on the basis of a competitive review process and the scientific merit of their proposals. The wide range of disciplines they represent and their research interests demonstrated the diversity and complexity inherent in studying health care relationships.

• Development of an Instrument to Measure Patients' Trust of Health Care Providers
• Exploration of the Effect of Nausea, Self-Efficacy, and Health Care Relationships on Medication Adherence in HIV/AIDS Patients
• Advance Care Planning: A Team Approach
• Assisting Older Adults To Communicate Their Pain After Surgery
• The Effect of a Specialized RN Intervention Designed to Maximize Patient-Provider Relationships on Adherence to Anti-Depressant Medication
• Pilot Study of Rapid Electronic Adherence Reporting with Provider Feedback on Adherence to Antiretroviral Therapy (HCR 01-12)
• Development of a Measure of Family Management of Childhood Chronic Illness
• The Contribution of Health Care Professionals to Parent and Child Self-Management of Type 1 Diabetes
• Enhancing Treatment Access and Adherence among Women of Hispanic Origin: The Roles of Relationships and Cultural Responsiveness in Behavioral Health Care
• Elicitation of Patient with Adaptive Conjoint Analysis

Advance Care Planning: A Team Approach

B. Blechner, T. Babor, D. Paturzo, J. Rosen, and M. Lavery

Background
Most leading professional organizations consider advance care planning (ACP) an essential component of routine health care in the primary care physician's (PCP) office and a critical means of improving medical care at the end of life. The support of non-physician healthcare professionals as part of a PCP team can help a busy practitioner assure that patients receive the proper information they need about initiating ACP. The UConn Health Center's Department of Community Medicine, along with Pro-Health Physicians, a community-based primary care organization evaluated the effectiveness of an interactive, personalized team approach, using a nurse-educator (NE) as the hub of the team, to promote ACP in the primary care setting.

Hypothesis Researchers
hypothesized that a personalized, inter-active experimental approach with a trained nurse educator would show more promise for promoting ACP than a passive, physicians-only approach, by providing opportunities for patient discussion, fostering family interaction on the topic of end-of-life wishes, and encouraging the formulation of written advance directives.

Methodology
Among the 142 primary care Pro Health physicians invited to participate in the current study, 40 expressed interest. Investigators randomly selected 10 of these, and assigned them to active or passive intervention groups. At each of the 10 physician sites 20 patients were randomly chosen from a patient population fitting the following criteria: English-speaking, over 18 years old, no acute illness, no evidence of prior ACP in their records, and no evidence of dementia. Each physician completed a pre-test and a posttest and attended a one-hour training session about ACP and use of the Toolkit of resource materials for patients developed by researchers. All physicians used a standardized script in talking to patients. Physicians in the passive group gave the information kit to 100 of the randomly chosen patients to take home and read. At the active sites, the NE hired by the project gave each of the 100 patients the materials and reviewed them in a 25-minute, individual discussion session. All physicians were given four posters designed by the researchers to place in their waiting and examining rooms. After about two months, telephone interviews then mailing, if necessary, were conducted with patients to evaluate progress with the ACP process.

Results
All patients in the study showed improvement in their readiness to change regarding ACP. Eleven percent (11%) of patients in the passive group and 14% in the active group reached a stage of "determination" (preparing for some kind of action). Sixty-nine percent (69%) in the passive group and 76% in the active group moved to the final stage of change, by taking some action. Regarding the actual practice of ACP, 80% of the passive group and 84% of the active group read the material that was given to them; 60% in the passive group and 82% in the active group spoke with family members (a statistically significant and very important difference); while 4% in the passive group and 9% in the active group initiated written paperwork. Eleven percent (11%) of the passive group compared to 14% of the active group reported that they had completed the suggested form. None of the completed forms from the passive group were submitted but seven (12% - a statistically significant difference) from the active group were returned to physicians' offices. Using a summary score of six ACP activities, analysis of variance indicated a significant interaction effect between type of ACP (active, passive) and age. Younger patients in the active condition engaged in significantly more ACP activities than those younger patients in the passive condition. In contrast, older patients, who tended to have higher scores than younger patients, had similar ACP scores regardless of whether they were in the active or passive condition. Lastly, there was a significant difference between those in the active group (67%) who felt that a nurse educator would be of value in the doctor's office and those in the passive group (44%).

Physicians in our study strongly agreed that the ACP project was beneficial to patients and the practice and a valuable learning experience. They felt the main barrier to undertaking ACP was insufficient time. On a scale of 1 (strongly disagree) to 5 (strongly agree), time pressures were rated with an average score of 4.7. In the physician exit interview, seven of the ten physicians indicated that they would continue to discuss ACP with patients after the study.

Conclusion
Physicians found the project beneficial to patients and a valuable learning experience but cited the main barrier to undertaking ACP was insufficient time. Patients who interacted with the NE were significantly more enthusiastic about the value of having a NE in the physician's office than those in the passive group. Of statistical significance is the fact that the NE increased the total number of forms filed in the doctor's offices by 12%, and significantly more individuals in the active group spoke to their families about ACP. Singer et al (1998) observed that the most desirable outcome of ACP is family discussion and understanding of patient wishes, not necessarily written directives. The results also show that 1) the NE was effective in stimulating ACP in younger patients (under 50), and 2) PCPs can give out material about ACP to move patients along the stages of change almost as well as adding the additional resource of a NE. Patients cited procrastination as the primary reason for failing to complete forms. Further study of patient motivation and other mechanisms for accomplishing ACP both filing forms and talking to families is recommended.

Copyright 2003Yale University School of Nursing, Yale University, New Haven, CT 06536All Rights Reserved