title: Development and validation of a questionnaire to detect behavior change in multiple advance care planning behaviors.
abstract: BACKGROUND
  Advance directives have traditionally been considered the gold standard for advance care planning. However, recent evidence suggests that advance care planning involves a series of multiple discrete behaviors for which people are in varying stages of behavior change. The goal of our study was to develop and validate a survey to measure the full advance care planning process.
  
  
  METHODS
  The Advance Care Planning Engagement Survey assesses "Process Measures" of factors known from Behavior Change Theory to affect behavior (knowledge, contemplation, self-efficacy, and readiness, using 5-point Likert scales) and "Action Measures" (yes/no) of multiple behaviors related to surrogate decision makers, values and quality of life, flexibility for surrogate decision making, and informed decision making. We administered surveys at baseline and 1 week later to 50 diverse, older adults from San Francisco hospitals. Internal consistency reliability of Process Measures was assessed using Cronbach's alpha (only continuous variables) and test-retest reliability of Process and Action Measures was examined using intraclass correlations. For discriminant validity, we compared Process and Action Measure scores between this cohort and 20 healthy college students (mean age 23.2 years, SD 2.7).
  
  
  RESULTS
  Mean age was 69.3 (SD 10.5) and 42% were non-White. The survey took a mean of 21.4 minutes (±6.2) to administer. The survey had good internal consistency (Process Measures Cronbach's alpha, 0.94) and test-retest reliability (Process Measures intraclass correlation, 0.70; Action Measures, 0.87). Both Process and Action Measure scores were higher in the older than younger group, p<.001.
  
  
  CONCLUSIONS
  A new Advance Care Planning Engagement Survey that measures behavior change (knowledge, contemplation, self-efficacy, and readiness) and multiple advance care planning actions demonstrates good reliability and validity. Further research is needed to assess whether survey scores improve in response to advance care planning interventions and whether scores are associated with receipt of care consistent with one's wishes.
authors.affiliation: San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America ; Department of Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Sudore
authors.forename: Anita L
authors.initials: AL
authors.lastname: Stewart
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Knight
authors.forename: Ryan D
authors.initials: RD
authors.lastname: McMahan
authors.forename: Mariko
authors.initials: M
authors.lastname: Feuz
authors.forename: Yinghui
authors.initials: Y
authors.lastname: Miao
authors.forename: Deborah E
authors.initials: DE
authors.lastname: Barnes
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D032722:Advance Care Planning; D000368:Aged; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000523:psychology; D055815:Young Adult
references.citation: J Am Geriatr Soc. 2007 Feb;55(2):277-83
references.pmid: 17302667
references.citation: Patient Educ Couns. 2007 Dec;69(1-3):165-95
references.pmid: 17942272
references.citation: J Am Geriatr Soc. 2008 Jun;56(6):1006-13
references.pmid: 18410324
references.citation: Psychol Bull. 1979 Mar;86(2):420-8
references.pmid: 18839484
references.citation: Cancer Epidemiol Biomarkers Prev. 1995 Sep;4(6):649-54
references.pmid: 8547832
references.citation: J Am Geriatr Soc. 2010 Dec;58(12):2329-36
references.pmid: 21143441
references.citation: Can J Nurs Res. 1997 Fall;29(3):21-43
references.pmid: 9505581
references.citation: J Am Geriatr Soc. 1975 Oct;23(10):433-41
references.pmid: 1159263
references.citation: Psychol Rev. 1977 Mar;84(2):191-215
references.pmid: 847061
references.citation: J Gen Intern Med. 2011 Mar;26(3):265-71
references.pmid: 21057882
references.citation: J Clin Outcomes Manag. 2009 Jan 1;16(1):20-29
references.pmid: 20046798
references.citation: Ann Intern Med. 2010 Aug 17;153(4):256-61
references.pmid: 20713793
references.citation: J Pain Symptom Manage. 2013 Sep;46(3):355-65
references.pmid: 23200188
references.citation: J Gen Intern Med. 2008 Nov;23(11):1854-7
references.pmid: 18716849
references.citation: Patient Educ Couns. 2012 Jan;86(1):25-32
references.pmid: 21741194