Exploring patients’ advance care planning needs during the annual 75+ health assessment: survey of Australian GPs’ views and current practice
Joel Rhee
A B * , Mariko Carey C D , Alison Zucca C D and David Lambkin D
A The Discipline of General Practice, School of Population Health, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia.
B General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia.
C School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.
D Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
Australian Journal of Primary Health - https://doi.org/10.1071/PY22227
Submitted: 10 October 2022 Accepted: 7 July 2023 Published online: 10 August 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of La Trobe University. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Background: The 75+ health assessment has been identified as a suitable trigger to introduce advance care planning (ACP) to general practice patients. Australian general practitioners (GPs) were surveyed to explore their perceptions, attitudes and practices in introducing ACP during 75+ health assessments.
Methods: A cross-sectional postal survey of Australian GPs covering their personal, professional and workplace characteristics, their current practice regarding ACP within a 75+ health assessment, and their attitude towards ACP. Multivariate logistic regression was used to analyse the factors associated with routinely discussing ACP as part of the 75+ health assessment.
Results: A total of 185 (19.2%) out of 964 eligible GPs returned a completed survey. Most GPs reported that patients interested in ACP were supported by the GPs or the practice nurse. Two factors, (1) attitude that ACP is an essential component of the 75+ health assessment, and (2) regional or rural location of the practice, had a statistically and clinically significant association with the GP’s self-reported discussion of ACP during 75+ health assessments.
Conclusions: GPs showed a high level of support and involvement in discussing ACP during 75+ health assessments. ACP support during 75+ health assessments was often provided directly by the GP or via the practice nurse. Given the international evidence that ACP training programs improve skills and knowledge, and foster positive attitudes towards ACP, there is an important need to continue funding ACP training programs for GPs and practice nurses.
Keywords: 75+ health assessment, advance care planning, annual health assessment, cross-sectional survey, general practice, general practitioners, older adults, primary care.
Introduction
Advance care planning (ACP) is an important component of comprehensive care of older people, especially those with chronic and life-limiting illnesses (Lum et al. 2015). General practice, with its focus on long-term care for people living in the community, is an ideal setting for ACP (RACGP 2012). Unfortunately, ACP remains uncommon in general practice, with a recent study showing that only 3.2% of patients have an advance care directive in their medical record (Detering et al. 2019). General practices face multiple barriers, including uncertainty regarding legal standing of ACP, lack of time and adequate funding, and difficulty raising a topic that could potentially be distressing to the patient (Rhee et al. 2013; Fan and Rhee 2017).
To overcome these barriers, the 75+ health assessment has been identified as a good opportunity to introduce patients to ACP (Rhee et al. 2013; ELDAC 2021). The 75+ health assessment provides funding for GPs and practice nurses to undertake comprehensive history and physical examination on an annual basis to identify and proactively manage the health care needs of older people (Hamirudin et al. 2015). Unfortunately, the uptake of 75+ health assessments remains low, at only ~20% of the eligible population (Hamirudin et al. 2015). In a recent qualitative study, GPs, practice nurses and patients found the incorporation of ACP into 75+ health assessments to be feasible and acceptable (Franklin et al. 2020).
In this paper, we report on the findings of a survey of Australian GPs conducted to examine their perceptions of the important components of the 75+ health assessment. The aim of the study was to determine Australian GPs’: (1) perceptions of their current practice regarding ACP within a 75+ health assessment, including what was discussed, and how needs were managed when identified; (2) attitudes towards ACP; and (3) factors associated with self-reported ACP practice within the 75+ health assessment.
Methods
Eligibility criteria
GPs practising in Australia. GPs on extended leave, retired or for whom no current mailing address was available were excluded.
Sampling and recruitment
A random sample of 1000 GPs across Australia was drawn from the Australian Medical Publishing Company database. The Australian Medical Publishing Company database holds records of approximately 83% of all practising Australian GPs (Department of Health (Australia) 2017). Fifteen of the GPs selected had no contact details listed in the database, leaving 985 (75% metropolitan and 25% non-metropolitan) potentially eligible. GPs were mailed a study invitation, a copy of the survey and a reply-paid envelope. Up to two written reminders were sent to non-responders. Participants received a A$20 gift voucher as a token of appreciation upon return of the survey.
Measures
The survey was developed by the investigators with expertise in aged and dementia care, advance care planning, and primary palliative care. An expert advisory group consisting of geriatricians, GPs, nurses and researchers was convened to provide feedback on the draft survey. Specifically, they were asked to provide feedback on the content of the survey, and refinement of the wording of the questions. Additional assessment items were also added as a result of this process.
Participants were asked to indicate how important it is to assess legal issues and documents, advance care planning, living will, enduring guardian, and enduring power of attorney as part of a 75+ health assessment. Responses were provided on a 4-point Likert scale: (1) essential – should be done in every health assessment; (2) important but not essential – should be done in most health assessments; (3) optional – should be done if it’s required for a particular patient; and (4) not important – should not be done as part of a health assessment. Participants were asked to indicate who (‘Nurse or GP’ or ‘GP only’) should assess the ‘legal issues and documents, advance care planning, living will, enduring guardian, enduring power of attorney’.
GPs were asked to estimate how many 75+ health assessments they had conducted in the past month. Three items assessed GP perceptions of their current practice regarding ACP during a 75+ health assessment. GPs were asked whether they routinely discuss ACP as part of a health assessment (yes/no). Those who indicated ‘yes’ were asked, ‘Which aspects of advance care planning do you discuss?’ Response options were ‘patient’s values and preferences’; ‘Appointing a substitute decision maker;’ or ‘Completing a written advance care directive.’
Participants were asked to self-report their age, sex and number of years practising as a GP, whether they are a fellow of the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine, and the number of GPs and nurses working in their practice.
An alpha level of 0.05 was specified for all tests and confidence intervals. The data were analysed in SAS v9.4.
Descriptive statistics are presented as count (%). Factors associated with routinely discussing ACP as part of a health assessment were assessed using logistic regression. Model assumptions were checked and found to be acceptable. Results are presented as odds ratios (95% CI) and P-values for both univariate and multivariate models. ‘Age’ is presented as an overall Wald type III P-value and pairwise comparisons for each category, with reference ‘46–65’.
‘Number of GPs (FTE)’, ‘Number of nurses (FTE)’ and ‘Number of 75+ health assessments in last month’ were recorded as continuous variables, but were all found to be non-linear and so were assessed categorically. Each was dichotomised and cut-off points were specified to produce approximately equal group sizes.
The number of factors included in the multivariate analysis was capped at seven due to the low number of events (n = 63) in the outcome (answering ‘no’ to the question, ‘Do you routinely discuss advance care planning as part of a 75+ health assessment?’). A subset of factors was chosen based on clinical significance, which were: attitude, sex, years practising, practice location, number of GPs, number of nurses and number of 75+ health assessments in the last month.
Results
Participant characteristics (Table 1)
Of the 985 GPs who were invited to participate, 21 were subsequently judged ineligible. Of the eligible GPs (n = 964), 185 (19.2%) returned a completed survey. There were no differences in the sex (χ2(1) = 0.420, P = 0.517) or geographic location (χ2(1) = 0.673, P = 0.412) of consenters and non-consenters (note: sex and geographic locations were obtained from the Australian Medical Publishing Company database for the purpose of comparing consenters and non-consenters). Just over half of the participants were men, and the majority were aged ≥46 years and practised in a metropolitan area. Over half of all GPs had been practising for >20 years, and most were fellows of the Royal Australian College of General Practitioners or Australian College of Rural and Remote Medicine. Age and sex distribution for all Australian GPs is provided for comparison (Table 1).
| Characteristic | Class | Do you routinely discuss advance care planning as part of a health assessment? | All Australian GPs (2020) (Commonwealth of Australia 2022) | ||
|---|---|---|---|---|---|
| Yes (n = 118) | No (n = 63) | Total (n = 185)A | |||
| AttitudeB | Essential | 84 (76%) | 26 (24%) | 111 (60%) | |
| Non-essential | 34 (48%) | 37 (52%) | 73 (40%) | ||
| Missing | 0 | 0 | 1 | ||
| Gender | Male | 62 (66%) | 32 (34%) | 97 (52%) | Male: 52% |
| Female | 56 (64%) | 31 (36%) | 88 (48%) | Female: 48% | |
| Age | ≤45 years | 30 (71%) | 12 (29%) | 42 (23%) | ≤39 years: 26% |
| 46–65 years | 72 (69%) | 33 (31%) | 105 (59%) | 40–64 years: 59% | |
| ≥66 years | 16 (50%) | 16 (50%) | 32 (18%) | ||
| Missing | 0 | 2 | 6 | ||
| Years practising | ≤20 years | 53 (67%) | 26 (33%) | 79 (44%) | |
| >20 years | 65 (64%) | 37 (36%) | 102 (56%) | ||
| Missing | 0 | 0 | 4 | ||
| Practicie location | City | 79 (60%) | 53 (40%) | 135 (73%) | |
| Regional/remote | 39 (80%) | 10 (20%) | 50 (27%) | ||
| College fellowship | RACGP or ACRRM | 95 (66%) | 48 (34%) | 143 (79%) | |
| Not a rember | 23 (61%) | 15 (39%) | 38 (21%) | ||
| Missing | 0 | 0 | 4 | ||
| No. of GPs (FTE) | <5 | 47 (57%) | 36 (43%) | 83 (46%) | |
| ≥5 | 71 (72%) | 27 (28%) | 98 (54%) | ||
| Missing | 0 | 0 | 4 | ||
| No. of nurses (FTE) | <2 | 38 (54%) | 32 (46%) | 70 (39%) | |
| ≥2 | 78 (72%) | 30 (28%) | 108 (61%) | ||
| Missing | 2 | 1 | 7 | ||
| No. of 75+ health assessments in last month | <4 | 45 (56%) | 35 (44%) | 80 (47%) | |
| ≥4 | 64 (70%) | 28 (30%) | 92 (53%) | ||
| Missing | 9 | 0 | 13 | ||
ARows may not sum to total due to missing data for routine ACP discussion.
BParticipants were asked to indicate how important it is to assess legal issues and documents, advance care planning, living will, enduring guardian, and enduring power of attorney as part of a 75+ health assessment.
Self-reported ACP activities during 75+ health assessments
Approximately half (n = 80, 47%) of GPs reported conducting four or more 75+ health assessments in the past month. Almost two-thirds (n = 118, 65%) indicated that they routinely discuss ACP during the 75+ health assessment. Of those who routinely discuss advance care planning, 84% (n = 98) discussed patients’ values and preferences; 80% (n = 94) discussed completing a written advance care directive; and 74% (n = 87) discussed appointing a substitute decision maker. The majority of GPs (141, 82%) indicated a nurse or a GP could discuss ACP during the 75+ health assessment. However, 31 (18%) indicated that ACP should only be discussed with a GP.
Table 2 details the actions taken by GPs when a patient expresses an interest in ACP. Most provided the patient with written information and directly helped the patient with ACP. The nurse also helped the patient. Some GPs referred the patient to a local ACP expert, to a lawyer or to another resource.
| Action | n | % |
|---|---|---|
| Provide written information | 77 | 65 |
| GP helps the patient with ACP | 73 | 62 |
| Nurse helps the patient with ACP | 44 | 37 |
| Refer to a local ACP expert who can assist the patient | 19 | 16 |
| Refer to a lawyer | 16 | 14 |
| Other (specified in open-ended responses) | ||
| ‘Refer to internet resources’ | 14 | 12 |
| ‘Encourage family discussion’ | 4 | 4 |
| ‘JP’A | 1 | 1 |
| ‘Social worker’ | 1 | 1 |
AJustice of the Peace.
Attitude towards ACP during 75+ health assessments
Sixty percent of participating GPs (n = 111) indicated that ACP was essential (should be done at every health assessment), and 25% thought it was important (should be done for most health assessments) to cover ACP in 75+ health assessments.
Factors influencing routine discussion of ACP during 75+ health assessments
After adjusting for sex, years practising, number of GPs, number of nurses and number of 75+ health assessments in the past month, an association was observed between routine discussion of ACP as part of a 75+ health assessment, and both attitude and practice location. GPs who considered ACP as an essential part of a 75+ health assessment were more likely to report discussing ACP during 75+ health assessment than those who did not consider it to be essential (OR 2.80; CI 1.41–5.56). GPs practising in regional or remote areas were more likely to report routinely discussing ACP during 75+ health assessments than those who worked in cities (OR 2.33; CI 1.02–5.32). The associations with GP characteristics and routinely discussing ACP as part of a 75+ health assessment are shown in Table 3.
| Characteristic | Measure | n | Univariate | P-value | Multivariate (n = 169) | |
|---|---|---|---|---|---|---|
| OR (95% CI) | OR (95% CI) | P-value | ||||
| AttitudeA | Essential vs non-essential | 181 | 3.52 (1.85, 6.67) | <0.001 | 2.80 (1.41, 5.56) | 0.003 |
| Sex | Male vs female | 181 | 1.07 (0.58, 1.98) | 0.823 | 1.13 (0.56, 2.27) | 0.731 |
| Years practising | ≤20 years vs >20 years | 181 | 1.16 (0.62, 2.15) | 0.638 | 1.03 (0.51, 2.07) | 0.937 |
| Practice location | Regional/remote vs city | 181 | 2.62 (1.20, 5.69) | 0.015 | 2.33 (1.02, 5.32) | 0.045 |
| No. of GPs (FTE) | ≥5 vs <5 | 181 | 2.01 (1.08, 3.75) | 0.027 | 1.09 (0.45, 2.66) | 0.846 |
| No. of nurses (FTE) | ≥2 vs <2 | 178 | 2.19 (1.16, 4.12) | 0.015 | 1.63 (0.67, 3.97) | 0.283 |
| No. of 75+ health assessments in past month | ≥4 vs <4 | 172 | 1.78 (0.95, 3.33) | 0.072 | 1.54 (0.78, 3.05) | 0.214 |
AParticipants were asked to indicate how important it is to assess legal issues and documents, advance care planning, living will, enduring guardian, and enduring power of attorney as part of a 75+ health assessment.
Discussion
Our findings highlight the positive attitude and involvement that Australian GPs have in ACP, and the usefulness of 75+ health assessment as a good opportunity for introducing ACP. Sixty-five percent of the participating GPs routinely discussed ACP during 75+ health assessments, and 60% considered ACP to be an essential component of the 75+ health assessment. There are no similar Australian surveys to compare these findings with, but in a recent audit, only 3.2% of primary care patients had an advance care directive in their medical records (Detering et al. 2019). The difference in prevalence may be explained partly by the fact that the audit study assessed the presence of documents in the clinical records, included a younger population and did not specifically examine people undertaking the 75+ health assessment. However, another possibility for the difference is that not all ACP discussions in primary care lead to formal documentation. There can be several reasons for this, including that some people choose to not complete a formal ACP document, but another possible explanation is that although the 75+ health assessment may be useful for introducing ACP, more time and follow-up sessions may be required to develop and formalise advance care directives, and allow in-depth discussions of the key issues. In a study of Australian general practices, the first ACP discussion took an average of 32 min (range 10–75 min), and the mean number of visits for ACP was 2.4 (range 1–4; Miller et al. 2019).
The current study shows that when patients are interested in further discussions about ACP, this is often done in-house within the practice, either by the GPs or the practice nurse. A smaller, but substantial, proportion of GPs ‘outsourced’ ACP to an external facilitator or a legal professional. It should be noted that the GPs’ responses to this question and reported practices may reflect the availability and/or their awareness of relevant referral-based services assisting with ACP. General practices should be provided support so that they can continue to encourage and help their patients with ACP. This includes not only patient education resources, but training of GPs and practice nurses in ACP, and funding for practice nurses to have follow-up ACP discussions with patients after the 75+ health assessment.
Of the several factors examined to determine their association with ‘routinely discussing ACP as part of 75+ health assessment’, attitude and practice location were found to be statistically significant in the multivariate analysis. The latter finding is not surprising, given the expanded role that many GPs in rural and regional locations are required to undertake, including the provision of end-of-life care without substantive specialist support (Fletcher et al. 2016; Littlewood et al. 2019). Both of these factors had a high OR (2.80 and 2.33, respectively), and given our finding that 65% of GPs routinely discuss ACP during 75+ health assessments, we consider the magnitude of these effect sizes as clinically significant.
In recent years, the Australian government has funded several training programs to train GPs and practice nurses in ACP, and a number of government-funded organisations provide up-to-date resources to consumers and health professionals, and help raise the awareness of ACP in the community and among health professionals (Tran et al. 2018; Advance Care Planning Australia 2023). International evidence shows that health professional training programs in ACP improve not only skills and knowledge, but imbue health professionals with positive attitudes about ACP (Chan et al. 2019). Our finding showing the importance of GP’s attitude as the most important predictor to their reported clinical practice highlights the importance of continued funding of these programs, not only for education and training, but to positively influence the health professionals’ attitudes to ACP.
Strengths and limitations of the study
An important strength of the study is recruitment strategy using a random sample of GPs across Australia, with good representation from rural and urban areas. Although the modest response rate (19.2%) is not dissimilar to similar surveys of GPs conducted in Australia (Halkett et al. 2014; Parkinson et al. 2015; Herrmann et al. 2019; Abeyweera et al. 2021), it is possible that the participant sample may not be representative of Australian GPs, and skewed to GPs with a greater interest in aged care. Although the questionnaire was piloted with GPs and other health care professionalss, it has not been formally validated.
Conclusion
Our survey of Australian GPs showed a high level of support and involvement in discussing ACP during 75+ health assessments. Two factors, (1) attitude that ACP is an essential component of the 75+ health assessment, and (2) regional or rural location of the practice, had a significant association with the GP’s self-reported practice in discussing ACP during 75+ health assessments. Our findings show the need to continue encouraging and supporting general practices to continue ACP as part of the 75+ health assessments. Moreover, given the international evidence that ACP training programs improve not only skills and knowledge, but imbue participants with positive attitudes to ACP, there is an important need to continue funding ACP training programs for GPs and practice nurses.
Data availability
The data collected in this study is not available to other researchers due to privacy and confidentiality reasons.
Conflicts of interest
Prof Mariko Carey reports grants from National Health and Medical Research Council during the conduct of the study.
Declaration of funding
This research was supported by the National Health and Medical Research Council via a Dementia Research Team grant (APP1095078). Mariko Carey is supported by a NHMRC Boosting Dementia Research Leadership Fellowship (APP1136168). This research was also supported by infrastructure funding from the Hunter Medical Research Institute.
Acknowledgements
The authors acknowledge Sarah Tew and Grace Norton for research assistance, and Sandra Dowley for data entry.
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