Impact of Structured Advance Care Planning Conversations on Clinical Outcomes in High Risk Hospitalized Patients

Background

We examined associations between structured advance care planning (ACP) conversations and outcomes in high-risk hospitalized patients. Methods: We conducted a retrospective cohort study of patients hospitalized on the general medicine service from January 2021-March 2024 who were flagged as high-risk by two algorithms: top quartile of predicted 12-month mortality and ≥20% predicted 30-day readmission. Multivariable generalized linear regression models assessed the association between documented structured ACP conversations and the primary outcome of 30-day readmission. Secondary outcomes included discharge disposition, length of stay, and in-hospital and post-discharge mortality. Results: Among 6,944 high-risk patients, 1,166 (16.8%) had structured ACP documentation. Patients in the ACP group had higher case mix indices, 30-day readmission (49.0% vs. 30.5%), and longer hospital stays (55.5 vs 29.9 days) compared to the No ACP group. Structured ACP was independently associated with 30-day readmission (adjusted OR 2.10; 95% CI, 1.84–2.39). In-hospital mortality was similar (0.2% vs 0.4%), but among those who died post-discharge, time to death was shorter in the ACP group (132.8 vs 159.9 days). Discharge patterns suggested greater hospice referral (adjusted OR 1.25; 95% CI, 0.97–1.62) and lower skilled-nursing facility use (adjusted OR 0.86; 95% CI, 0.73–1.01) in the ACP group. Conclusion: In this cohort of high-risk hospitalized patients, structured ACP conversations associated with a higher 30-day readmission rate and a trend towards hospice discharge. These findings highlight the care complexity of high-risk inpatients and underscore the need for prospective studies to clarify causal effects, optimal timing, and implementation strategies for ACP in the hospital.