Title: Missed Opportunities and Health Disparities for Advance Care Planning Before Elective Surgery in Older Adults

Background:  Planning for an elective surgical procedure provides opportunity to review patients’ wishes regarding not only the upcoming surgery, but overall goals of care. The procedure itself is a “touchpoint” with the healthcare system and includes a formal informed consent discussion, including how the surgery or resultant complications may adversely affect a patient’s life. Logically, this encounter could result in advance care planning to enhance goal-concordant care as a valuable outcome. National surgical society guidelines¹ recommend advance care planning (ACP) around surgical care and Centers for Medicare and Medicaid Services (CMS) financially incentivizes the completion of ACP documents. How often does ACP occur preoperatively to an elective surgical procedure?

Design and Participants: This single-center, retrospective study of adults > 65 years of age who underwent elective surgery with planned overnight admission of 1 night or more was performed using electronic health record (EHR), National Surgical Quality Improvement Project (NSQIP) and California state death registry data. All patients who underwent surgery in 2019 by general surgery, surgical oncology, cardiac, vascular, plastic, abdominal transplant, orthopedic, neurosurgery, urology, and otolaryngology services at the University of California San Francisco Health hospitals were included. Self-identified race and ethnicity data and preferred language were collected as were patient comorbidities via American Society of Anesthesiologists (ASA) classification and Charlson Comorbidity Index. To evaluate effects of social determinants of health on ACP completion, zip codes were obtained and linked to a ranked “neighborhood deprivation index.” Descriptive statistics and multivariate logistic regression was used to evaluate effects of covariates on ACP completion.

Results:  ACP documentation rate in the EMR within 90 days prior to surgery was 14.7% (539 patients) among the 3671 participants. Advance directives comprised 83% and POLST forms 11% of the ACP documentation. Only 11% of participants had ACP notes (as identified by “bookend” function in the EMR) entered prior to surgery and 90% of these were entered by a primary care provider or social worker. None of the ACP notes were entered by surgical providers. 75% of the ACP notes were uploaded to the EMR on the day of surgery, raising the question of the context of the conversation—was it directly related to surgery or had it occurred prior to planned surgery? Prior to the surgery, ACP was not documented in ~ 82% of patients who were either admitted to the ICU or who were discharged to a facility. Factors associated with absent preoperative ACP were male sex and non-English preferred language. Having Medicare insurance was associated with preoperative ACP. Patients who had preoperative ACP had a 1-year mortality of 10% compared to 6% for those without ACP. Amazingly, 85% of patients 75 years and older did not have documented ACP prior to surgery. The authors did not find a correlation between NSQIP-defined severe morbidities and completion of preoperative ACP. Surgical subgroups having the highest rate of preoperative ACP were cardiac (18%), vascular (17%) and abdominal transplant (16%). Demographic analysis revealed a higher rate of preoperative ACP for White patients, those with commercial insurance and a low Charlson Comorbidity Index; whereas patients from lower socioeconomic status, of Asian or Latinx race/ethnicity and with higher Charlson Comoribidy Indices had lower rates of ACP.

Commentary: This study revealed that despite surgical society guidelines and CMS incentives to address ACP at time of elective surgical procedures, preoperative completion/documentation of ACP discussions is extremely low. Surprisingly, ACP doesn’t occur even in those having morbidities shown to increase perioperative risks. Like other studies about health disparities, minority patients, those for whom English is not the primary language, and those from socioeconomic deprivation are less likely to have engagement in ACP preoperatively.  Interestingly, men were less likely than women to have ACP discussions. These findings corroborate a missed opportunity for important and contextual ACP discussions. The authors point to research associating ACP with decreased anxiety/depression, PTSD and complicated grief as benefits. They advocate that striving toward equity in ACP should include “targeted” efforts at language-concordant and culturally sensitive care, but they don’t offer detailed ideas about how to achieve such. Study findings that patients with higher perioperative risk were not more likely to engage in ACP were disturbing with the authors suggesting that ACP might be better implemented via a population-level intervention. Their example of a tool such as “PREPARE for Your Care” adapted to fit the surgical population is intriguing. The usual barriers to ACP---lack of time, lack of training, discomfort with the topic—are discussed and are not unique to surgical providers.

Bottom Line:  ACP prior to surgery occurs uncommonly, even when patients may be at high risk for complications. Men, minorities, non-English speakers, and the socieconomically deprived are most often to be ignored in ACP. Surgical teams continue to require substantial support in order to achieve preoperative ACP. This support can potentially be provided by PC teams (education and training), cross-trained role models (the surgeon/PC provider), and changes to core surgical curricula embedding training in ACP. Overcoming barriers to engaging in ACP by surgical professionals, however, requires a multi-faceted, innovative approach, perhaps including empowering patients and their families to bring up these important topics. We must also recognize that changing surgical culture is likely to be a slow, generational process.

References: 1. Cooper, L., Abbett, S.K., Feng, A., Bernacki, R.E., Cooper, Z., Urman, R.D. et al. Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement. J Am Geriatr Soc. 2020; 68: 1941-1946. https://doi.org/10.1111/jgs.16681Links to an external site.

Source: Colley A, Lin JA, Pierce L, Finlayson E, Sudore RL, Wick E. Missed Opportunities and Health Disparities for Advance Care Planning Before Elective Surgery in Older Adults. JAMA Surg. 2022;157(10):e223687. doi:10.1001/jamasurg.2022.3687.