Low Completion and Disparities in Advance Care Planning Activities Among Older Medicare Beneficiaries

Advance care planning (ACP) is an iterative process that includes discussions about preferences for end-of-life (EOL) care, completion of advance directives (AD), and designation of a surrogate decision maker in a durable power of attorney for health care (DPOA).^1,2 Engagement in ACP has increased over time.³ However, the rising tide of ACP may not have lifted all boats equally. Minorities, those with lower levels of educational attainment, and the poor may not have benefited from rising rates of ACP to the same extent that white, highly educated, affluent individuals have. Rates of ACP by older Latinos in particular are unknown. Further, we do not know if ACP uptake is greater among those in worse health and with poorer prognoses.

We used data from the National Health and Aging Trends Study (NHATS), a longitudinal cohort study using a nationally representative sample of community-dwelling Medicare beneficiaries ages 65 years and older (2011 round 1 response rate, 71%; 2012 round 2 response rate, 86%).⁴ This cross-sectional analysis used a random one-third sample of 2015 participants who responded to a supplemental module on ACP fielded in 2012. This study was considered exempt by the institutional review board of the University of California, San Francisco.

Outcome variables included 3 self-reported elements of ACP: (1) discussing with any individual the medical treatment desired if seriously ill in the future (EOL discussion), (2) having legal arrangements for a proxy to make decisions about medical care (DPOA), or (3) having written instructions about medical treatment desired (AD) (exact wording at nhatsdata.org). Predictor characteristics included self-reported age, sex, race/ethnicity, education, income, self-rated health, number of chronic conditions, disability in activities of daily living (ADLs), and dementia.

We investigated the strength and magnitude of the relationship between sociodemographic and health characteristics of older adults and engagement in ACP using logistic regression analysis and predicted probabilities calculations, adjusted for age, sex, and race/ethnicity. An exploratory analysis stratified Latinos by interview language. Analytic weights were used to account for complex sampling strategy. Hosmer-Lemeshow tests suggested that multivariable models had adequate goodness of fit.

Of 2015 participants, 1156 (60%) reported having an EOL discussion, 997 (50%) a DPOA, and 1027 (52%) an AD; 580 (27%) reported no ACP elements, and 723 (38%) reported all 3 ACP elements (Table 1).

The predicted prevalence of each element of ACP differed by up to 35% between patient characteristic subgroups and was lower for 2 or more ACP elements among adults ages 65 to 74 years, men, African Americans, Latinos, those with lower levels of educational attainment, and lower annual income (Table 2). Older Spanish-speaking Latinos had the lowest predicted prevalence of ACP of any group examined: 19% reporting EOL discussion, 20% DPOA, and 17% AD.

We found little to no increase in predicted prevalence of ACP among older adults with multimorbidity or ADL disability (Table 2). Older adults with dementia had significantly lower predicted prevalence of EOL discussions (54%) and ADs (46%) compared with those with no dementia (62% and 54%, respectively).

Our findings suggest that in 2012, more than quarter of older Medicare beneficiaries had not engaged in ACP. Those who were Latino, African American, poorly educated, or low income were at highest risk. Counter to expectation that people likely to have more interaction with medical providers would have higher prevalence of ACP, we found that those with dementia and more ADL disability either had similar or lower prevalence of ACP engagement.

In 2016, the Centers for Medicare and Medicaid Services began reimbursing physicians for engaging Medicare beneficiaries in ACP. While reimbursement is a critical step forward, effective, targeted approaches are needed to ensure increased completion of ACP among all older adults. Innovative ACP communication strategies are being developed both for minority populations and populations of older adults with multimorbidity and dementia.⁵ In the future, clinicians should use these tailored tools when discussing ACP with these particularly vulnerable groups.

Corresponding Author: Krista Lyn Harrison, PhD, Division of Geriatrics, School of Medicine, University of California, San Francisco, 4150 Clement St VA181G, San Francisco, CA 94121 (krista.harrison@ucsf.edu).

Published Online: October 31, 2016. doi:10.1001/jamainternmed.2016.6751

Author Contributions: Dr Harrison had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All Authors.

Acquisition, analysis, or interpretation of data: Harrison, Adrion, Ritchie, Smith.

Drafting of the manuscript: Harrison, Adrion, Ritchie, Sudore.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Harrison, Adrion, Smith.

Obtained funding: Smith.

Administrative, technical, or material support: Harrison, Ritchie, Sudore.

Study supervision: Sudore, Smith.

No additional contributions: Ritchie.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Harrison was supported by the National Institute of Aging, T32-AG000212. Dr Adrion was supported by the Agency for Healthcare Research and Quality, T32 HS000053-24. D. Smith was funded by a K23 Beeson award from the National Institute on Aging (K23AG040772) and the American Federation for Aging Research. Statistical consultation was provided with support from UCSF’s Claude D. Pepper Center.

Role of the Funder/Sponsor: The funding institutions had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.