Abstract
IMPORTANCE: The onset of the COVID-19 pandemic created urgency for advance care planning, including documenting goals-of-care conversations (GoCCs), while seismically disrupting usual health care delivery. Characterizing trends in GoCC rates during the pandemic can provide insight into the extent to which health care systems prioritized advance care planning in the face of competing clinical demands, shifts to telemedicine, and staffing shortages. OBJECTIVE: To determine how the COVID-19 pandemic was associated with changes in outpatient first-ever GoCCs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of patients eligible for their first-ever documented GoCC in outpatient clinics at 123 US Veterans Health Administration facilities nationwide from March 2019 to February 2023. EXPOSURE: COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: National- and facility-level weekly GoCC rates, defined as number of first-ever documented GoCCs per 100 000 outpatient appointments. Secondary analyses examined associations between facility-level characteristics and facility GoCC rates. RESULTS: Of 5 027 956 patients nationally, 124 216 (2.5%) had a first-ever outpatient GoCC during the study period (facility-level range: 0.01%-26.3%). The mean (SD) weekly national first-ever outpatient GoCC rate was 99.6 (12.1) in the year preceding the pandemic. At pandemic onset, mean weekly outpatient GoCC rates dropped to a nadir of 74.1 (week of March 21, 2020), then sharply increased, peaking at 177.4 (week of April 18, 2020), before steadily declining to pre-COVID-19 rates and ending with a COVID year 3 mean (SD) of 96.6 (11.5). At the facility level, 29 of 123 facilities (23.6%) significantly increased outpatient GoCC rates in the early pandemic and maintained or further improved through COVID year 3, with significant rate increases pre-COVID to COVID year 3. CONCLUSIONS AND RELEVANCE: In this retrospective cohort study of outpatient GoCC rates, the early COVID-19 pandemic was associated with initial disruption and then with increased first-ever outpatient GoCC rates nationally. Despite unprecedented challenges to health care delivery, several facilities increased GoCC rates during the first COVID-19 surge and maintained increased rates through 2023. These facilities could serve as models for best practices to improve advance care planning.