Home›Primary Care & Family Medicine› Four mailer types aim to increase health care proxy documentation in patients with chronic conditions
Four mailer types aim to increase health care proxy documentation in patients with chronic conditionsNew trial plans to use mailers to help patients name proxies
medRxivPublished September 12, 2026Study authors: Cloughesy, J. N.; Chang, T. Y.; Enguidanos, S.; Jacobson, M.DOI ↗Editorial oversight: Dr. Sofia Müller, MD · Lifespan & Whole-Person Care
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Key Takeaway
Note that this is a study protocol only; no results are currently available to inform clinical practice.
This study protocol describes a factorial randomized trial involving approximately 20,000 patients aged 55 years or older, or 18 years or older with cancer, congestive heart failure, or chronic kidney disease. The target population includes patients without a documented health care proxy in their electronic health record (EHR) who have an upcoming in-person primary care visit.
The intervention consists of four types of mailers designed to encourage the designation of a health care proxy. These mailers vary based on the presence or absence of a pre-commitment prompt and whether the mailer is sent from the patient's primary care provider or the health system. The primary comparator is no mailer under usual care.
The primary outcome is the EHR-documentation of a health care proxy within 30 days of the index visit. Secondary outcomes include proxy documentation at 90 days, legal advance care planning documentation at 30 and 90 days, and visit attendance.
As this is a study protocol, no results, effect sizes, or safety data are reported. The study aims to evaluate low-cost, scalable behavioral interventions to increase health care proxy documentation. Clinical application is currently limited as the trial has not been conducted.
How this fits prior evidence
How this fits prior evidence: This study addresses a gap in behavioral interventions for patients with chronic conditions, such as those with chronic kidney disease or cancer. While previous coverage noted that high abdominal aortic calcification index predicts poorer cardiovascular event-free survival in patients with chronic kidney disease and that play interventions reduce anxiety in children with cancer, this protocol focuses on the administrative and logistical aspects of care for these populations.
When a person faces a serious illness like cancer or heart failure, making big decisions can be overwhelming. One of the most important things a person can do is name a healthcare proxy. This is a person who can make medical decisions for them if they become too sick to speak for themselves.
Researchers are designing a study to see if mailers can help more people get this done. They will test four different types of mailers. These mailers will vary by whether they include a pre-commitment prompt and whether they come from a primary doctor or the health system. The goal is to see if these simple tools can help patients document their choices in their electronic records.
Because this is a study protocol, the results are not available yet. The study will involve about 20,000 patients in a Northern California health system. The researchers want to find a low-cost way to make sure patients have a plan in place before an emergency happens.
What this means for you:
A new trial will test if different mailer designs help patients name a healthcare proxy.
Common questions
What is a healthcare proxy?
A healthcare proxy is a person you choose to make medical decisions for you if you become too ill to speak for yourself. This is especially important for people managing serious conditions like cancer, heart failure, or chronic kidney disease. The study aims to see if mailers can help more people get this legal step completed.
Who is included in this study?
The study plans to include about 20,000 patients in a Northern California health system. These patients will be 55 or older, or 18 or older if they have cancer, heart failure, or chronic kidney disease. They are specifically chosen because they do not currently have a healthcare proxy listed in their electronic records.
Are the results of the mailer study available yet?
No, the results are not available yet. This document is a study protocol, which means it is the plan for a study that has not been completed. The researchers will eventually look at how many patients document a proxy within 30 or 90 days after receiving the mailers.
Introduction Health care proxies serve as surrogate decision-makers for patients with limited decisional capacity, yet only one in three U.S. adults have designated one. This trial will evaluate low-cost, scalable behavioral interventions embedded in previsit mailed outreach to increase health care proxy documentation. Methods and analysis In this 2 x 2 + 1 factorial superiority trial, approximately 20,000 patients with an upcoming in-person primary care visit at a Northern California health system will be randomized over a 12-month period into one of four intervention mailers encouraging designation of a health care proxy, or to no mailer under usual care. Eligible patients will have no documentation of a health care proxy in the electronic health record (EHR) and will be aged 55 years or older, or 18 years or older with cancer, congestive heart failure, or chronic kidney disease. The four mailers differ by the presence or absence of a pre-commitment prompt, and whether the mailer is sent from the patient's primary care provider or the health system. The primary outcome is EHR-documentation of a health care proxy by 30 days after the index scheduled visit date. Secondary outcomes include proxy documentation through 90 days, legal advance care planning documentation through 30 and 90 days, and visit attendance. We will use logistic regression to estimate the intention-to-treat effect of receiving any intervention mailer versus no mailer, a pre-commitment mailer versus a mailer without pre-commitment, and a provider-signed versus health system-signed mailer. Ethics and dissemination The University of Southern California Institutional Review Board approved the protocol and granted a waiver of informed consent for this minimal-risk trial. Results will be posted on ClinicalTrials.gov within one year of the primary completion date. Trial Registration The trial was prospectively registered on December 12, 2025 at ClinicalTrials.gov (NCT07290478).
