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BACKGROUND: Discussions about advance directives should be offered to all nursing home residents. Managed Medicare programs for nursing home residents allow for the development of performance improvement initiatives to ensure that these discussions occur and are documented. PURPOSE: To assess the effectiveness of an intervention to increase discussion and documentation of advance directives for enrollees in a managed Medicare program for nursing home residents, and to evaluate whether this intervention affected preferences for cardiopulmonary resuscitation (CPR) and hospitalization among enrollees. SUBJECTS: Participants were 4,248 enrollees in a managed Medicare program in 1996, and 6,598 enrollees in 1997, in Georgia, Maryland, Massachusetts, Minnesota, Arizona, and Florida. DESIGN: Descriptive study of a quality improvement initiative. METHODS: A chart review was conducted in the fall of 1996 to determine the prevalence of documented advance directive discussions among all enrollees, and the preferences regarding CPR and hospitalization. Because the discussion rates varied across sites, and were lower than expected, each site developed strategies to improve advance directive discussion and documentation. One year later, a similar survey was conducted to determine the efficacy of the interventions, as well as to assess the impact, if any, on rates of desire for CPR and hospitalization. RESULTS: Documented discussions of advance directives increased across the six sites from 73% to 85% (P < 0.001). The overall percentage of patients desiring CPR did not change following the intervention (18%). However, there were geographical differences in the desire for CPR among enrollees, with those in Minnesota (8%), Arizona (11%), and Florida (12%) desiring it the least, and those in Massachusetts (20%), Georgia (29%), and Maryland (29%) desiring it the most. The overall percentage of desire for hospitalization decreased from 65% to 62% (P < 0.001). Enrollees in Georgia were most likely to want hospitalization (87%), and enrollees in Minnesota were the least likely to want hospitalization (57%). CONCLUSIONS: In a managed care program, documentation of advance directive discussions can be increased with focused efforts. Overall, most enrollees did not desire CPR, but a majority desired hospitalization. Despite the similarity of interventions and program philosophy across sites, significant geographic variations in desire for CPR and hospitalization remained.