Disparities in Advance Care Planning: Gaps in Clinical Notes on Comfort VS. Life-Sustaining Treatment Preferences

TL;DR

The study finds disparities in documenting patient preferences for comfort vs. life-sustaining treatments in electronic health records, with differences based on diagnosis and demographics.

Contribution

A novel application of NLP (Priorities-BERT) identifies disparities in advance care planning documentation across patient groups.

Findings

Heart failure and dementia patients are more likely to have comfort preferences documented.

Cancer patients are more likely to have life-sustaining treatment preferences documented.

Older age is associated with lower odds of life-sustaining treatment preferences being documented.

Abstract

Goal-concordant care is essential, yet disparities in advance care planning (ACP) persist. Electronic health record (EHRs) documentation of specific preferences, such as comfort and life-sustaining treatments (LST) and natural language processing (NLP) to extract free-text data, provides real-world information to explore patterns.

To identify predictors associated with documentation of specific preferences in a cohort of older adults with chronic conditions.

In a dataset of records from 14,729 older adults with heart failure, cancer, or dementia from a large academic medical center, we used a validated NLP model, Priorities-BERT (accuracy= 90.91%), to categorize documented care preferences from 3.6 million EHR notes into four groups: comfort-only, LST-only, mixed, or none. Logistic regression identified factors associated with each preference category (vs. no preference).

The mean age of the sample was 78.67 years (SD = 6.05). Female patients (vs. male) (OR = 1.11, 95% CI: 1.04–1.19), heart failure (OR =1.59, 95% CI: 1.34–1.89), dementia (OR = 1.33, 95%CI: 1.25-1.43), were associated with higher odds of having any priorities of care documented. Increasing age was associated with lower odds of LST (OR = 0.94, 95%CI: 0.94-0.95). Patients with heart failure (OR = 1.50, 95%CI: 1.39-1.61) or dementia (OR = 1.56, 95% CI: 1.42-1.71) were more likely to have comfort preferences documented. Conversely, cancer patients were more likely to have LST documented (OR = 1.12, 95%CI: 1.03-1.21).

Significant disparities existed across these three diagnoses in documentation ACP preferences. Targeted clinical and health-system interventions are needed to promote equitable and timely ACP conversations for patients likely to benefit from this care.