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Effectiveness of Computer-Generated Reminders for Increasing Discussions about Advance Directives and Completion of Advance Directive Forms: A Randomized, Controlled Trial

Paul R. Dexter, MD; Fredric D. Wolinsky, PhD; Gregory P. Gramelspacher, MD; Xiao-Hua Zhou, PhD; George J. Eckert, MAS; Marina Waisburd, MS; and William M. Tierney, MD
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Disclaimer: The opinions expressed herein are solely those of the authors and do not necessarily represent their institutions or the funding agency. Acknowledgments: The authors thank the physicians and nurses of the General Medicine Practice for their time and patience. Grant Support: By grant R01-HS07632 from the Agency for Health Care Policy and Research. Requests for Reprints: William M. Tierncy, MD, Regenstrief Institute for Health Care, 1001 West 10th Street, Indianapolis, IN 46202. Current Author Addresses: Drs. Dexter, Zhou, and Tierney and Ms. Waisburd: Regenstrief Institute for Health Care, 1001 West 10th Street, Indianapolis, IN 46202.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;128(2):102-110. doi:10.7326/0003-4819-128-2-199801150-00005
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Background: Physicians can increase the rate of completion of advance directive forms by discussing directives with their patients, but the means by which physicians can be induced to initiate these discussions are unclear. Computer-generated reminders have been shown to increase physician compliance with practice guidelines.

Objective: To determine the effects of computer-generated reminders to physicians on the frequency of advance directive discussions between patients and their primary caregivers and the frequency of consequent establishment of advance directives.

Design: Randomized, controlled trial with a 2 × 2 factorial design.

Setting: An outpatient general medicine practice associated with an urban public hospital.

Participants: Participants were 1) 1009 patients who were at least 75 years of age or were at least 50 years of age with serious underlying disease and 2) 147 primary care physicians (108 housestaff and 39 faculty).

Intervention: Computer-generated reminders that recommended discussion of one or both of two types of advance directives compared with no reminders.

Measurements: Discussions about advance directives, determined by patient interviews after all scheduled patient–physician outpatient encounters, and completed advance directive forms. The study period was approximately 1 year.

Results: Physicians who did not receive reminders (controls) discussed advance directives with 4% of the study patients compared with 24% for physicians who received both types of reminders (adjusted odds ratio, 7.7 [95% CI, 3.4 to 18]; P < 0. 001). Physicians who did not receive reminders completed advance directive forms with only 4% of their study patients compared with 15% for physicians who received both types of reminders (adjusted odds ratio, 7.0 [CI, 2.9 to 17]; P < 0.001). Overall, 45% of patients with whom advance directives were discussed completed at least one type of advance directive.

Conclusions: Simple computer-generated reminders aimed at primary caregivers can increase the rates of discussion of advance directives and completion of advance directive forms among elderly outpatients with serious illnesses.


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Figure 1.
General Medicine Practice encounter form showing reminders for both types of advance directive.
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