Background Advance care planning/serious illness conversations can help clinicians understand patients’ values and preferences. There are limited data on how to increase these conversations, and their effect on care patterns. We hypothesized that using a machine learning survival model to select patients for serious illness conversations, along with trained care coaches to conduct the conversations, would increase uptake in cancer patients at high risk of short-term mortality. Methods We conducted a cluster-randomized stepped wedge study on the physician level. Oncologists entered the intervention condition in a random order over six months. Adult patients with metastatic cancer were included. Patients with <2 year computer-predicted survival and no prognosis documentation were classified as high-priority for serious illness conversations. In the intervention condition, providers received automated weekly emails highlighting high-priority patients and were asked to document prognosis for them. Care coaches reached out to these patients to conduct the remainder of the conversation. The primary endpoint was proportion of visits with prognosis documentation within 14 days. Results 6,372 visits in 1,825 patients were included in the primary analysis. The proportion of visits with prognosis documentation within 14 days was higher in the intervention condition than control condition: 2.9% vs 1.1% (adjusted odds ratio 4.3, p < .0001). The proportion of visits with advance care planning documentation was also higher in the intervention condition: 7.7% vs 1.8% (adjusted odds ratio 14.2, p < .0001). In high-priority visits, advance care planning documentation rate in intervention/control visits was 24.2% vs 4.0%. Conclusion The intervention increased documented conversations, with contributions by both providers and care coaches.

中文翻译：

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自动化患者选择和护理教练，以增加癌症患者的预先护理计划


背景 预先护理计划/严重疾病对话可以帮助临床医生了解患者的价值观和偏好。关于如何增加这些对话及其对护理模式的影响的数据有限。我们假设，使用机器学习生存模型来选择患者进行严重疾病对话，并由训练有素的护理教练进行对话，将增加短期死亡风险高的癌症患者的接受度。方法 我们在医生层面进行了整群随机阶梯楔形研究。肿瘤学家在六个月内以随机顺序进入干预条件。患有转移性癌症的成年患者也被纳入其中。计算机预测生存率为 <2 年且没有预后文件的患者被列为严重疾病对话的高优先级患者。在干预条件下，提供者每周都会收到一封自动发送的电子邮件，其中强调了高优先级患者，并被要求记录他们的预后。护理教练联系了这些患者，进行了剩下的谈话。主要终点是 14 天内有预后记录的就诊比例。结果 1,825 名患者的 6,372 次就诊纳入了初步分析。干预条件下 14 天内有预后记录的就诊比例高于对照条件：2.9% vs 1.1%（调整后优势比 4.3，p < .0001）。在干预条件下，带有预先护理计划文件的就诊比例也较高：7.7% vs 1.8%（调整后优势比 14.2，p < .0001）。在高优先级就诊中，干预/对照就诊中的预先护理计划记录率分别为 24.2% 和 4.0%。 结论 干预措施增加了有记录的对话，提供者和护理教练都做出了贡献。