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Am Fam Physician. 2005;72(4):694

Fifteen to 25 percent of adults complete advance directives (ADs), usually after a serious illness or hospitalization. Initiatives encouraging healthy patients to complete ADs have had moderate success. These initiatives have included patient educational materials as well as model discussions and computerized reminders for doctors. Wissow and colleagues performed a physician-based intervention and studied the rate of new AD filings by older patients following intervention.

The prospective, quasi-experimental study included patients older than 65 years who were scheduled for routine health mainte nance at five urban and suburban interven tion health centers. The comparison group included patients who received no interven tion, but study participants were not com pletely matched with intervention patients Intervention included a group discussion with physicians, reminders placed in patient charts, and educational materials designed to assist physicians with initiating and con ducting AD-related conversations. Patients in the intervention group received letters reminding them of the importance of ADs.

The final analysis included 2,120 patients (842 intervention and 1,278 comparison patients). By the end of the study, 7.8 percent of intervention patients had filed new ADs, compared with 0.7 percent of comparison patients. Older age and higher income were associated with increased completion rates Sex, ethnicity, number of chronic conditions, and emergency department admission rates did not affect completion rates. A follow-up survey of physicians found that time restrictions limited AD discussions, particularly with patients who had difficulty under standing the issues. All physicians reported that at least some of the written materials were useful (especially chart reminders), but some did not feel they needed the training discussion.

The authors conclude that physician based intervention moderately increased the rate of new AD filings. The authors suggest that more intensive physician-based inter ventions as well as additional measures to meet the needs of low-income patients may create even higher completion rates.

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