Advance care planning (ACP) is a process by which individuals choose their goals of care, quality of life priorities, and potential future medical intervention preferences and then communicate these values [1-3]. Actions taken during ACP include choosing a surrogate decision-maker (SDM), completing advance directives, and discussing a patient’s wishes with loved ones and health care providers. With increasing average lifespans, ACP is a vital component of high-quality care to ensure that patients’ care when facing serious illness is concordant with their values and goals. Currently, anywhere between 3% to 47% of patients may receive medical care that is not consistent with the patient or their loved ones’ wishes [4-6]. Because of these inconsistencies, it’s estimated that US $75.7 billion to US $101.2 billion is spent on overtreatment or low-value care each year in the United States [7]. These findings highlight the need to increase communication regarding medical care planning.

ACP is associated with decreased anxiety among patients’ family and caregivers [8], improved patient quality of life [9], decreased unwanted medical care [10-12], and decreased health care costs [13-16]. Despite the promising evidence of benefits [17], rates of ACP remain low, with many patients and families avoiding these discussions until the patient’s condition has deteriorated and is suboptimal for end-of-life decision-making. In addition, less than 11% of Medicare beneficiaries discuss ACP with their medical providers [18-21]. In the United States, approximately 37% or less of individuals report having some kind of advance directive, which could include a medical power of attorney or a living will [22,23]. ACP rates are often even lower within historically marginalized communities in America [24-28].

While the majority of patients express positive views or interest in ACP [22,29], they may not know how to begin the process. Initiation of ACP conversations seems to be a major barrier, as patients may be reluctant to broach the subject with their health care providers, while clinicians report having insufficient training or time to conduct ACP discussions [22,30,31] during busy clinic visits. Though patients believe that their medical providers should initiate conversations about ACP [32,33], 17% or fewer of patients report discussing ACP with their medical team [34]. Given the barriers for many patients in learning about and completing ACP, it is important to explore alternative approaches that may better support health care providers in facilitating this vital service [29]. Digital health tools could be a potential solution to improve equitable access to ACP for patients and to engage loved ones and health care providers in the process [35,36]. Scoping reviews have concluded that currently available web-based ACP programs are feasible and generally well-received by users [37,38], but the quality of the content greatly varies [39].

Current ACP online programs are primarily static web-based forms and do not include interactive educational content, plain language, or the capability to allow for official signing of ACP documentation [40]. Other ACP programs are geared toward specific patient populations and are therefore not generalizable to all individuals. Additionally, the sections on medical interventions in many online ACP resources fail to mention some common life support treatments that an individual may experience at end of life or with serious illness [41]. Several available smartphone apps also provide some education or actionable decision-making in regard to ACP, but currently available apps lack sufficient features or have poor functionality, limiting their practicality [42].

The Koda digital ACP platform seeks to fill the gaps found in current offerings by providing a highly interactive solution that is suitable for all technological knowledge levels and more inclusive of the most common life-support treatment options. The platform guides patients through a personalized, interactive guide, which includes video-based educational content and decision-making guides for patients and their loved ones. Users are able to select health care goals and indicate their wishes regarding potential future medical interventions, all of which auto-generate into easily accessible documentation that can be shared with loved ones and health care providers. Koda was created to help facilitate informed discussions of ACP and to provide a tool that patients could use freely and effectively without an added time burden for clinicians.

A previous retrospective report on Koda [43] was conducted with a sample of patients with serious illness. The findings of that quality improvement report showed that 53% of referred patients completed their ACP through the platform. However, due to the retrospective nature of this prior study, we were unable to assess self-report usability metrics or change in opinions or knowledge after platform use. The main objective of this study was to determine the reach, adoption, and usability of Koda to conduct digital ACP within a university health system.

This pilot study assessed the feasibility and acceptability of using a web-based interactive ACP platform, Koda Health, to help older adults think about their overall health-related goals, document those goals in an advance directive, and assign an SDM. We found that the intervention was acceptable to older adults and feasible to implement. This was highlighted by the fact that 80% of enrolled participants completed the entire intervention and created an advance directive.

Our findings also suggest that the Koda platform was able to bridge the gap in ACP engagement between different racial groups. Previous reports have shown that individuals from often-marginalized racial communities are less likely to have engaged in ACP [26,28]. However, when comparing the 2 main self-identified race categories in our data, we found no substantial difference—80.95% of Black patients and 79.66% of White patients who enrolled in the study went on to complete using the Koda platform. This adds to the existing literature that indicates that digital ACP platforms have the potential to address health disparities by providing accessible, user-friendly tools to all users, regardless of their racial background [43,53].

In addition, the SUS score of 76.2 indicates that users generally found the Koda platform easy to use and had a positive overall experience. This score suggests that Koda’s interface and features were well designed, allowing users to navigate and interact with the system without substantial barriers. We also found that patient age was not correlated with system usability ratings (r=.03; P=.76), suggesting that the platform was similarly user-friendly across the sample age range (50-99 years). However, while the overall usability was rated as good, there may still be room for improvement. It will be important to analyze usability metrics in more detail to identify specific areas where the platform can be enhanced. This could involve conducting further user testing, collecting qualitative feedback, or conducting additional surveys to gather more insights.

Participants also reported learning new information about ACP and being more ready to have conversations about medical care after completing the plan. While the self-reported changes in knowledge and readiness were statistically significant, we cannot yet accurately determine the degree of clinical significance. Generally, clinically significant improvements are associated with any positive increase to an average 5-point rating. However, more research is needed to determine specific thresholds for outcomes on ACP-related metrics [17,49]. Nevertheless, these findings have positive implications for the ability of online health tools to promote ACP participation among patients and families, with the ultimate goal of bringing empowerment and peace of mind during serious illness or end-of-life care.

Despite these promising findings, several limitations must be acknowledged. First, the study intervention necessitates further validation through a randomized controlled trial. Second, the low enrollment rate compared to the total number of invitees suggest that more effective recruitment methods are needed than a single patient portal message, such as personalized ACP information from a nurse or other health care provider, posters placed in prominent areas, or additional contact methods. Additionally, as in any voluntary research, responses may have been affected by self-selection bias; those who agreed to participate in the study may be distinct from those who chose to ignore the invitation to participate. We saw evidence of this in the greater percentage of female-identifying participants in the study than in the general population. Future studies should consider appropriate sampling techniques like stratified randomization to ensure participation reflective of the larger population. Lastly, further studies should investigate the long-term impacts of the Koda platform on measures of patient and caregiver experience and goal-concordant care [54].

In conclusion, the Koda ACP platform represents a promising tool for promoting patient engagement in ACP, particularly among older adults and marginalized groups. By facilitating knowledge acquisition and readiness to engage in ACP, the Koda platform can help empower patients to make goal-informed medical decisions, especially regarding end-of-life care. Further research is needed to validate these findings and determine long-term impacts on patient and caregiver outcomes.