Serious Illness Conversations in Older Patients at High Risk of Mortality in Primary Care During the COVID-19 Pandemic: A Quasi-Experimental Study

Purpose: Serious Illness Conversations (SICs) are essential to delivering person-centered care for older adults with chronic conditions, but are rarely integrated into routine primary care. To address this gap, we compared the effectiveness of a structured training strategy versus passive dissemination of educational materials on SIC documentation rates during the COVID-19 pandemic. Methods: A quasi-experimental study across 13 primary care clinics in Quebec, Canada. Five clinics received structured team-based Serious Illness Care Program training (intervention group) with a provincially disseminated SIC toolkit and eight received the toolkit only (control group). The primary outcome was the proportion of patients with a documented SIC across three time periods (Period 1, pre pandemic; Period 2, pandemic initial wave; and Period 3, post dissemination of SIC toolkit). We used generalized estimating equations (GEE). Results: Across 13 clinics, 2,368 eligible patients (mean age 75.8 years (SD = 7.5), 54% female, with a mean Charlson Comorbidity Index of 4.88 (SD = 2)) accounted for 19,134 clinical visits, 49.5% in person and 49.6% virtually. SIC documentation rates were 3.3% (control) and 3.4% (intervention) in Period 1, 9.3% and 4.3% in Period 2, and 6.4% and 4.8% in Period 3, respectively. There was no statistically significant improvement to SIC documentation in the intervention group at Period 2 nor Period 3. Conclusion: Structured training was not more effective than passive dissemination for SIC documentation. Educational interventions must be supported by structural changes, workflow integration, and organizational leadership. Multi-level implementation strategies are needed to embed SICs sustainably into primary care.