Background Advance care planning and serious illness conversations can help clinicians understand patients’ values and preferences. Data are limited on how to increase the number of these conversations and what their effects are 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 patients with cancer 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 6 months. Adult patients with metastatic cancer were included. Patients with a less than 2-year computer-predicted survival and no prognosis documentation were classified as high priority for serious illness conversations. In the intervention condition, clinicians received automated weekly emails highlighting high-priority patients and were asked to document prognoses for them. Care coaches contacted these patients to conduct the remainder of the conversation. The primary endpoint was the proportion of visits with prognosis documentation within 14 days. Results We included 6372 visits with 1825 patients in the primary analysis. The proportion of visits with prognosis documentation within 14 days was higher in the intervention condition than in the control condition: 2.9% vs 1.1% (adjusted odds ratio = 4.3, P < .001). 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 < .001). For high-priority visits, the advance care planning documentation rate in intervention visits was 24.2% and in control visits was 4.0%. Conclusion The intervention increased documented conversations, with contributions by both clinicians and care coaches.

中文翻译：

---

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 预先护理计划和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的数量以及它们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，将增加短期死亡高风险癌症患者的接受率。方法 我们在医生层面进行了一项整群随机、阶梯式楔形研究。肿瘤学家在 6 个月内以随机顺序进入干预条件。纳入患有转移性癌症的成年患者。计算机预测生存期少于 2 年且无预后记录的患者被归类为严重疾病对话的高优先级。在干预条件下，临床医生每周都会收到自动电子邮件，突出显示高优先级患者，并被要求记录他们的预后。护理教练联系了这些患者进行剩余的对话。主要终点是 14 天内有预后记录的就诊比例。结果 我们在主要分析中纳入了 6372 次就诊，涉及 1825 名患者。干预条件下 14 天内有预后记录的就诊比例高于对照条件下：2.9% 对 1.1%（调整比值比 = 4.3，P < .001）。在干预条件下，有预先护理计划文件的就诊比例也更高：7.7% 对 1.8% （调整比值比 = 14.2，P < .001）。对于高优先级访视，干预访视的预先护理计划记录率为 24.2%，对照访视为 4.0%。 结论 干预增加了记录在案的对话，临床医生和护理教练都做出了贡献。