Observational studyJournal of general internal medicine2026
Anticipatory Advance Care Planning Visits and COVID-19 Treatment Intensity Among Medicare Fee-for-Service Beneficiaries: A Retrospective Observational Study.
Observational study in Journal of general internal medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundIn March 2020, professional organizations issued guidelines for anticipatory COVID-19 advance care planning (aACP) with high-risk older adults.
objectiveTo examine responses to these guidelines and associated COVID-19 treatment intensity.
designRetrospective regression discontinuity design (RDD) using 2020 Medicare Parts A and B claims to assess aACP receipt, by beneficiary COVID-19 mortality risk. Adjusted logistic regression to assess predictors of aACP and the association between aACP and COVID-related mechanical ventilation. PATIENTS: Medicare fee-for-service beneficiaries 66 and older enrolled on January 1, 2020. MAIN MEASURES: ACP visits assessed via current procedural terminology billing codes 99497 and 99498: classified as anticipatory if the place of service was ambulatory and outside an annual wellness visit. COVID-19 mortality risks based on age and/or co-morbidity and practice attribution were assessed pre-lockdown. Hospitalization within 2 weeks of COVID-19 diagnosis and associated mechanical ventilation (MV) were assessed post-lockdown. KEY
resultsIn total, 24,935,234 beneficiaries received 470,046,404 encounters in 2020; 1,578,331 were for ACP; of these, 318,813 (20%) were classified as anticipatory. Lockdown abruptly decreased all encounters. The RDD estimate found aACP decreased by 54% (95% CI= -0.62, -0.46); the relative decline in aACP was smaller for highest COVID-19 mortality risk groups: multimorbidity (-42%; 95% CI= -0.48, -0.35), patients with advanced cancer (-44%; 95% CI= -0.52, -0.36), dementia (-35%; 95% CI= -0.43, -0.27), or ESRD (-38%; 95% CI= -0.55, -0.21). Care from an integrated health system was associated with less aACP. Among 1,314,986 beneficiaries diagnosed with COVID-19, aACP was associated with an increase in adjusted 14-day hospitalization (OR = 1.21; 95% CI=1.17-1.26) but a decrease in invasive mechanical ventilation if hospitalized (OR = 0.85; 95% CI=0.77-0.96).
conclusionsProviders followed recommendations to conduct anticipatory COVID-19 ACP with their high-risk patients, which was associated with reduced COVID-19 treatment intensity. This underscores the need for effective identification and dissemination of clinical risk factors in the next pandemic to guide anticipatory decision making.
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