R. Lynae Roberts , Desh P. Mohan , Katelin D. Cherry , Samantha Sanky , Taylor R. Huffman , Christina Lukasko , Anthony Comito , Dara Hashemi , Zachary K. Menn , Tatiana Y. Fofanova and Julia D. Andrieni
The Journal of the American Board of Family Medicine October 2023, jabfm.2023.230133R2; DOI: https://doi.org/10.3122/jabfm.2023.230133R2
R. Lynae RobertsFrom Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
From Koda Health, Houston, TX, USA (RLR, DPM, KDC, SS, TRH, CL, AC, DH, TYF); Population Health, Houston Methodist Coordinated Care Accountable Care Organization, Houston, TX (ZKM, JDA); Weill Cornell Medical College, New York, NY (JDA); Houston Methodist, Department of Medicine, Houston TX (JDA).
Background: Advance care planning (ACP), a process of sharing one’s values and preferences for future medical treatments, can improve quality of life, reduce loved ones’ anxiety, and decrease unwanted medical utilization and costs. Despite benefits to patients and health care systems, ACP uptake often remains low, due partially to lack of knowledge and difficulty initiating discussions. Digital tools may help reduce these barriers to entry.
Methods: We retrospectively examined data from pilot deployment of Koda Health patient-facing ACP among Houston Methodist Coordinated Care patients, for quality improvement (QI) purposes. Patients referred by nurse navigators could access Koda’s digital platform, complete ACP, and share the legal documentation generated. Analyzed measures include usage rates and ACP-related decisions within the platform.
Results: Of eligible patients (n = 203), 52.7% voluntarily completed their plan. Engagement and completion rates were similar across demographics. Patients indicated majority preference (66.4%) toward spending the last days of life at home. Most patients indicated wanting no life-support intervention if quality of life became unacceptable (51 to 71% across 4 treatments). Life-support decisions were similar between demographic categories, excepting CPR and dialysis, wherein a greater portion of Black patients than White patients preferred at least trial intervention, rather than none.
Conclusions: As an observational QI analysis, limitations include bounded geographical reach and lack of data on ACP impacts to subsequent health care utilization, which future studies will address. Findings suggest that digital health tools like Koda can effectively facilitate equitable ACP access and may help support health systems and providers in offering comprehensive ACP.
Advance care planning (ACP) is the process by which individuals of any age or health status learn, decide, and share their values, quality of life priorities, health goals, and future medical treatment preferences. 1 ⇓ –3 ACP has been shown to ensure patients’ preferences are fulfilled, decrease anxiety among loved ones, improve patient quality of life, decrease unwanted utilization, and increase hospice utilization when appropriate. 4 ⇓ ⇓ ⇓ –8 Further, studies have demonstrated health care savings ranging from $3458 11 to $22,434 12 in the past 30 days of life, following discussion of ACP or documentation of those preferences.
Although many patients express interest in engaging in ACP, and up to 89% of patients believe that doctors should initiate ACP conversations, few patients take action to choose a surrogate decision maker (SDM), complete advance directives, or discuss their wishes with a loved one. 4,14,15 Only 7% to 17% report having had an ACP conversation with their medical provider. 16 The lack of engagement may be partially due to a justified lack of confidence in ACP, which is indeed often badly managed, 17,18 with at least 23% to 46.6% of patients receiving medical treatment that is inconsistent with their preferences or goals. 19,20 This lack of goal-concordant care leads to an estimated $75.7 billion to $101.2 billion spent on medical overtreatment or low-value care annually in the US. 21 Medicare has recognized the problem, and a framework for reimbursement of high-quality ACP is now in place. 22 However, the billing rate for Medicare beneficiaries is below 10% in most states. 23 ⇓ –25
ACP adoption is often even lower among historically marginalized communities – by a factor of 2 for African Americans. 26 ⇓ ⇓ ⇓ –30 Studies point toward the delivery of ACP dialog as a bottleneck: there is often a reluctance for patients to raise the topic to their primary care doctor. 31 Physicians, in turn, cite time pressure 32 and lack of training as impediments to initiating ACP discussions. 31 Given these barriers, it is critical to understand how we can better support health systems and their providers in delivering ACP. 33
Digital health tools may provide a means to reduce the number of barriers by providing a semistandardized conversation guide, facilitating document completion, and sharing care plans to inform loved ones and health care providers. Digital tools may also facilitate discussions with loved ones and reduce clinical burden to introduce this conversation and, whether a patient needs to begin the conversation or needs to update their preferences from an outdated directive. A recent review found that web-based ACP programs are associated with increased ACP knowledge, improved ACP communication with loved ones and health care providers, increased documentation, and are easy for participants to use. 34 Further, prior research on video-guided ACP has shown improvements in documentation, increased hospice utilization, and decreased costs. 11
This pilot retrospective analysis examined the feasibility and outcomes of deploying the Koda ACP software platform, built by digital health company Koda Health. The platform enables selection of health care goals, identification of life sustaining medical treatment preferences, and generation of legal documentation. The Koda platform aims to support health organizations and patients by easing the burden and encouraging informed ACP conversations. This retrospective review was conducted for quality improvement and health equity purposes to determine whether Koda facilitated ACP engagement to a greater and more equitable degree than commonly reported participation. We also describe specific ACP choices (eg, surrogate decision makers' relationship to patients, acceptable quality of life) for the respondents who completed these items and assess whether these selections differed between racial and socioeconomic categories.
For the purpose of quality improvement (QI), this retrospective observational analysis examined advance care planning, using utilization reports from the Koda Health digital ACP platform, with patients of Houston Methodist Coordinated Care (HMCC) Accountable Care Organization (ACO).
The Koda Health ACP platform is a web-application portal that provides patients with the tools to explore and define their ACP preferences. The platform can be accessed from any internet-connected device, including computers, phones, and tablets. The patient-facing Koda ACP platform is guided by a simple, easy to navigate interface that includes embedded videos with captions to provide evidence-based educational content to guide patients through the prompts. Patients first have the option to define their values, what they would consider unacceptable quality of life (eg, unable to dress themselves, in a coma, living in a nursing facility), and what is most important to them (eg, family, religion, hobbies). Users then learn about and select whether they would want to undergo different life support treatment options, in 2 different scenarios: in their current health state and if their quality of life became unacceptable. After writing in any additional preferences, patients can then identify at least 1 surrogate decision maker. The platform then auto-generates state-specific advance directives that can be signed or notarized electronically depending on state regulations. Patients are then able to share these documents with loved ones, as well as ensure that they are accessible in their referring health system’s electronic medical record (EMR). Users are able to make changes to their plan and send these updates to loved ones and health care providers at any time. Koda Health also employs trained, nonclinical advance care planning navigators to provide additional support for partner health systems and their patients. These navigators provide text, e-mail, and phone support to ensure patients can navigate the Koda ACP platform.
Houston Methodist Coordinated Care (HMCC) is an ACO participating in an Enhanced Track Medicare Shared Savings Program (MSSP) with approximately 50,800 Medicare fee-for-service patients attributed to more than 300 Primary Care physicians. Based on a predictive risk model, 38 higher risk Medicare Shared Savings Program patients are stratified into HMCC nursing outreach programs, including Complex Care and Advanced Illness (AIC). For patients in these higher risk groups, HMCC nurse navigators conduct routine telephonic outreach to provide patient education and longitudinal health care navigation. In the time frame of data included in this analysis, 6097 patients were identified by HMCC risk stratification to be included in their nurse navigator outreach. HMCC nurse navigators were trained on introducing Koda Health ACP tools and introduced Koda to a subset of this population when appropriate (eg, if the patient had not completed ACP or were at higher health risk). If patients who were introduced expressed interest, they were referred to Koda. As this was a pilot of Koda as a service, nurses in the value-based care program did not intend to refer all contacted patients to Koda. Inclusion criteria included HMCC patients, age 18 or older, who had decision making capacity, and who were English-speaking, as the Koda platform was only available in English at the time. Patients with moderate to severe dementia, severe hearing loss, or blindness were excluded for these particular analyses. Nurse navigators only referred patients who did not already have advance directives on file.
Referred patients were sent a link to the Koda ACP platform and were able to access and complete the Koda ACP platform asynchronously on any internet-connected device (eg, smartphone, tablet, desktop computer). When patients were referred from HMCC, Koda navigators sent the patients initial information about ACP and the Koda platform. Koda Navigators would call or e-mail once a week if patients had not taken any action on the platform, if they had started but not completed their plan, or if they had any questions. If after 8 weeks, there was no response or further action taken by the patient, the navigator support team would end regular contact. Data were collected from November 2020 to April 2022 as part of standard utilization reports.
Patient information and ACP preferences were assessed with usage data within the Koda platform wherein patients selected their values, life circumstances, quality of life preferences, and their preferences for future medical treatments in different possible scenarios. Completion of ACP was defined as completion of each section of the Koda platform, with the exception of official documentation. Completion of executed documents required signing or notarization of advance directives based on state requirements.
Neighborhood-level socioeconomic status was assessed using the Area Deprivation Index (ADI), 35 a validated measure which provides a rank from 1 to 100, with 1 indicating lowest level of disadvantage and 100 indicating highest level of disadvantage. Patients were assigned a national ADI ranking geocoded via US census data for each residential block in aggregate. Analyses were conducted with quintiles of ADI ranks.
We used descriptive statistics to assess the characteristics of the patient portal users and expressed them as central tendencies or frequencies with percentages. We used Chi-square tests to test for statistically significant distribution differences in categorical variables (race and ADI rank) for patients’ ACP platform choices. A Bonferroni correction was applied to adjust for multiple comparisons. For all inferential statistics, a p value < 0.05 was considered statistically significant. Analyses were performed using R version 4.2. 36
Over the 17-month data collection period, 203 patients were screened as eligible and enrolled into Koda Health ACP by the HMCC nursing team (see Figure 1). Enrolled patients were 75.5 (S.D. = 11.3) years of age on average, ranging from 30 to 102 years, 62.6% were Female and 37.4% Male. Based on ADI classification, 13.3% (27) were from the lowest SES, 22.2% (45) were from the lower-mid SES, 29.1% (59) were from the mid SES, 19.7% (40) are from the upper-mid SES, and 15.8% (32) are from the highest S.E. areas. See Table 1 for additional demographic characteristics.