What question did this study set out to answer?

This research aims to examine practice-level variations in the implementation and outcomes of advance care planning interventions in primary care settings.

February 11, 2026Journal of the American Geriatrics Society2 citations

Practice Variability in the SHARING Choices Pragmatic Trial of Primary Care Advance Care Planning

SDSydney DyJohns Hopkins University DSDanny ScerpellaJohns Hopkins University JWJennifer L WolffJohns Hopkins University

Key Points

This research aims to examine practice-level variations in the implementation and outcomes of advance care planning interventions in primary care settings.
Conducted an explanatory sequential mixed-methods analysis of quantitative and qualitative data.
Evaluated variation in key processes such as reach (contact) and uptake (conversations).
Assessed outcomes, including new electronic health record documentation of advance directives and the incidence of potentially burdensome care.
Substantial variation observed among practices in terms of ACP facilitator reach and uptake.
Significant correlation found between reach and new EHR advance directive documentation (p < 0.01).
No correlation identified between reach/uptake and potentially burdensome care at end of life.

Abstract

ABSTRACT Background Barriers to advance care planning intervention implementation and impact on outcomes at the patient, clinician, and health system levels are well‐documented. Understanding practice‐level variation in implementation and outcomes could elucidate relevant contextual factors and potential strategies for improving future implementation. We therefore examined practice variation and associations between processes and outcomes in the pragmatic trial of SHARING Choices, a primary care advance care planning (ACP) and communication intervention for older adults. Methods We conducted an explanatory sequential mixed‐methods analysis of quantitative variation among intervention practices in trial processes and outcomes, and qualitative interview analysis of ACP facilitators' perceptions of variation in implementation. We evaluated variation in key processes: (1) reach (phone contact between ACP facilitator and patient/family) and (2) uptake (facilitator‐led ACP conversations) and outcomes: (1) new electronic health record (EHR)‐documented advance directives (ADs) at 12 months and (2) receipt of potentially burdensome care within 6 months of death for Maryland residents with serious illness who died. We examined practice‐level correlations among processes and outcomes. Results Variation among practices was substantial for key processes (ACP facilitator reach and uptake) and outcomes (new EHR AD documentation and potentially burdensome care at end of life; all p < 0.01). Processes of reach and uptake were significantly correlated with the outcome of new EHR AD documentation but not with potentially burdensome care at end of life. ACP facilitators perceived variation in practice engagement with the intervention related to practice relationships and teams, relative priority of ACP, and resources such as space. Conclusions Practice variation in processes and mixed associations with outcomes highlight pragmatic trial implementation challenges and the impact and complexity of ACP. Future ACP trials should consider accounting for and evaluating practice variation in study design, implementation, and analysis.

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