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Scales DC, Cheskes S, Verbeek PR, Pinto R, Austin D, Brooks SC, Dainty KN, Goncharenko K, Mamdani M, Thorpe KE, Morrison LJ. Prehospital cooling to improve successful targeted temperature management after cardiac arrest: A randomized controlled trial. Resuscitation 2017; 121:187-194. [PMID: 28988962 DOI: 10.1016/j.resuscitation.2017.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/25/2017] [Accepted: 10/02/2017] [Indexed: 12/22/2022]
Abstract
RATIONALE Targeted temperature management (TTM) improves survival with good neurological outcome after out-of-hospital cardiac arrest (OHCA), but is delivered inconsistently and often with delay. OBJECTIVE To determine if prehospital cooling by paramedics leads to higher rates of 'successful TTM', defined as achieving a target temperature of 32-34°C within 6h of hospital arrival. METHODS Pragmatic RCT comparing prehospital cooling (surface ice packs, cold saline infusion, wristband reminders) initiated 5min after return of spontaneous circulation (ROSC) versus usual resuscitation and transport. The primary outcome was rate of 'successful TTM'; secondary outcomes were rates of applying TTM in hospital, survival with good neurological outcome, pulmonary edema in emergency department, and re-arrest during transport. RESULTS 585 patients were randomized to receive prehospital cooling (n=279) or control (n=306). Prehospital cooling did not increase rates of 'successful TTM' (30% vs 25%; RR, 1.17; 95% confidence interval [CI] 0.91-1.52; p=0.22), but increased rates of applying TTM in hospital (68% vs 56%; RR, 1.21; 95%CI 1.07-1.37; p=0.003). Survival with good neurological outcome (29% vs 26%; RR, 1.13, 95%CI 0.87-1.47; p=0.37) was similar. Prehospital cooling was not associated with re-arrest during transport (7.5% vs 8.2%; RR, 0.94; 95%CI 0.54-1.63; p=0.83) but was associated with decreased incidence of pulmonary edema in emergency department (12% vs 18%; RR, 0.66; 95%CI 0.44-0.99; p=0.04). CONCLUSIONS Prehospital cooling initiated 5min after ROSC did not increase rates of achieving a target temperature of 32-34°C within 6h of hospital arrival but was safe and increased application of TTM in hospital.
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Affiliation(s)
- D C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada.
| | - S Cheskes
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - P R Verbeek
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - R Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - D Austin
- Department of Emergency Medicine, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - S C Brooks
- Department of Emergency Medicine, Faculty of Health Sciences Queen's University, Kingston, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - K N Dainty
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - K Goncharenko
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - M Mamdani
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - K E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - L J Morrison
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Abstract
Techniques from behavioral economics-nudges-may help physicians increase pediatric vaccine compliance, but critics have objected that nudges can undermine autonomy. Since autonomy is a centrally important value in healthcare decision-making contexts, it counts against pediatric vaccination nudges if they undermine parental autonomy. Advocates for healthcare nudges have resisted the charge that nudges undermine autonomy, and the recent bioethics literature illustrates the current intractability of this debate. This article rejects a principle to which parties on both sides of this debate sometimes seem committed: that nudges are morally permissible only if they are consistent with autonomy. Instead, I argue that, at least in the case of pediatric vaccination, some autonomy-undermining nudges may be morally justified. This is because parental autonomy in pediatric decision-making is not as morally valuable as the autonomy of adult patients, and because the interests of both the vaccinated child and other members of the community can sometimes be weighty enough to justify autonomy-infringing pediatric vaccination nudges. This article concludes with a set of worries about the effect of pediatric vaccination nudges on parent-physician relationships, and it calls on the American Academy of Pediatrics to draw on scientific and bioethics research to develop guidelines for the use of nudges in pediatric practice and, in particular, for the use of pediatric vaccination nudges.
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Affiliation(s)
- Mark C Navin
- Department of Philosophy, Oakland University, 746 Mathematics and Science Center, Rochester, MI, 48309-4401, USA.
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103
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Arnold DR. Countervailing incentives in value-based payment. Healthcare (Basel) 2017; 5:125-128. [DOI: 10.1016/j.hjdsi.2016.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022] Open
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Affiliation(s)
- Erik R. Hoefgen
- Address for correspondence and reprint requests: Erik R. Hoefgen, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45229. Telephone: 513-636-6596; Fax: 513-803-9244;
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105
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Chiou H, Jopling JK, Scott JY, Ramsey M, Vranas K, Wagner TH, Milstein A. Detecting organisational innovations leading to improved ICU outcomes: a protocol for a double-blinded national positive deviance study of critical care delivery. BMJ Open 2017; 7:e015930. [PMID: 28615274 PMCID: PMC5541524 DOI: 10.1136/bmjopen-2017-015930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION There is substantial variability in intensive care unit (ICU) utilisation and quality of care. However, the factors that drive this variation are poorly understood. This study uses a novel adaptation of positive deviance approach-a methodology used in public health that assumes solutions to challenges already exist within the system to detect innovations that are likely to improve intensive care. METHODS AND ANALYSIS We used the Philips eICU Research Institute database, containing 3.3 million patient records from over 50 health systems across the USA. Acute Physiology and Chronic Health Evaluation IVa scores were used to identify the study cohort, which included ICU patients whose outcomes were felt to be most sensitive to organisational innovations. The primary outcomes included mortality and length of stay. Outcome measurements were directly standardised, and bootstrapped CIs were calculated with adjustment for false discovery rate. Using purposive sampling, we then generated a blinded list of five positive outliers and five negative comparators.Using rapid qualitative inquiry (RQI), blinded interdisciplinary site visit teams will conduct interviews and observations using a team ethnography approach. After data collection is completed, the data will be unblinded and analysed using a cross-case method to identify themes, patterns and innovations using a constant comparative grounded theory approach. This process detects the innovations in intensive care and supports an evaluation of how positive deviance and RQI methods can be adapted to healthcare. ETHICS AND DISSEMINATION The study protocol was approved by the Stanford University Institutional Review Board (reference: 39509). We plan on publishing study findings and methodological guidance in peer-reviewed academic journals, white papers and presentations at conferences.
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Affiliation(s)
- Howard Chiou
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Emory University School of Medicine Medical Scientist Training Program and Department of Anthropology, Emory University, Atlanta, USA
| | - Jeffrey K Jopling
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Gordon and Betty Moore Foundation, Palo Alto, USA
| | - Jennifer Yang Scott
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Meghan Ramsey
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Kelly Vranas
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Oregon Health & Science University, Portland, OR, USA
| | - Todd H Wagner
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
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106
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Preferences for Policy Options for Deceased Organ Donation for Transplantation: A Discrete Choice Experiment. Transplantation 2017; 100:1136-48. [PMID: 26457603 DOI: 10.1097/tp.0000000000000940] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite broad public support for organ donation, there is a chronic shortage of deceased donor organs. We sought to identify community preferences for features of organ donation policies. METHODS A discrete choice study was conducted using an online panel of Australian community respondents older than 18 years. Respondents were presented with scenarios comparing a "new" policy to the current policy. Tradeoffs between 8 policy aspects were quantified using mixed logit and latent class models: registration system, extent of donor family involvement, ease of registration, frequency of confirmation of intent, direct payment, and funeral expense reimbursement, priority for donor's family, and formal recognition of donation. RESULTS There were 2005 respondents (mean, 44.6 years). We found a strong preference for a new policy. Overall, respondents favored a policy that included: some involvement of the donor's family in the final decision, simple registration processes, less frequent reconfirmation of donation intent, direct payment or funeral expense reimbursement, and formal recognition of donation. However, there was significant preference heterogeneity across respondents, with various respondent groups valuing policy mechanisms differently. Respondents who viewed policy change negatively were also those who would be unlikely to be organ donors anyway, because they tended to hold negative views toward organ donation. CONCLUSIONS Our results suggest that the Australian community are open to alternative organ donation policies including changes to: registration systems, family involvement, and financial and nonfinancial mechanisms. Future policy discussions should not be limited by preconceived notions of what is acceptable to the community, rather informed by actual community values and preferences.
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Volpp K, Asch D. Make the healthy choice the easy choice: using behavioral economics to advance a culture of health. QJM 2017; 110:271-275. [PMID: 27803366 PMCID: PMC6257018 DOI: 10.1093/qjmed/hcw190] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Indexed: 11/14/2022] Open
Abstract
Despite great advances in the science and technology of health care, a large gap separates theoretically achievable advances in health from what individuals and populations actually achieve. Human behavior sits on the final common pathway to so many of our health and health care goals, including the prevention and management of illness and the fostering of wellness. Behavioral economics is a relatively new field offering approaches to supplement many of the conventional approaches to improving health behaviors that rely on education or standard economic theory. While those conventional approaches presume that an educated public will naturally make decisions that optimize personal welfare, approaches derived from behavioral economics harness existing and predictable patterns of behavior that often lead people to make choices against their best interests. By keeping these predictable patterns of behavior in mind when designing health insurance, health care programs or the health-related aspects of everyday life, behavioral economists aim to meet people half-way: no longer asking them to reshape their behavior to something more health promoting, but helping the behavioral patterns they already follow lead them to better health.
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Affiliation(s)
- K.G. Volpp
- From the Leonard Davis Institute Center for Health
Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
19104-6021, USA
- Center for Health Equity Research & Promotion, Philadelphia Veterans
Affairs Medical Center, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA 19104,
USA
| | - D.A. Asch
- From the Leonard Davis Institute Center for Health
Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
19104-6021, USA
- Center for Health Equity Research & Promotion, Philadelphia Veterans
Affairs Medical Center, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA 19104,
USA
- Address correspondence to D.A. Asch, 14–171 South Pavilion, 3400
Civic Center Boulevard, Philadelphia, PA 19104, USA.
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108
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Schwartz PH, Perkins SM, Schmidt KK, Muriello PF, Althouse S, Rawl SM. Providing Quantitative Information and a Nudge to Undergo Stool Testing in a Colorectal Cancer Screening Decision Aid: A Randomized Clinical Trial. Med Decis Making 2017; 37:688-702. [DOI: 10.1177/0272989x17698678] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Peter H. Schwartz
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA (PHS, KKS, PFM)
- Indiana University Center for Bioethics, Indianapolis, IN, USA (PHS, PFM)
- Philosophy Department, Indiana University School of Liberal Arts, Indianapolis, IN, USA (PHS)
- Indiana University Simon Cancer Center, Indianapolis, IN, USA (PHS, SMP, SMR)
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA (SMP, SA)
| | - Susan M. Perkins
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA (PHS, KKS, PFM)
- Indiana University Center for Bioethics, Indianapolis, IN, USA (PHS, PFM)
- Philosophy Department, Indiana University School of Liberal Arts, Indianapolis, IN, USA (PHS)
- Indiana University Simon Cancer Center, Indianapolis, IN, USA (PHS, SMP, SMR)
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA (SMP, SA)
| | - Karen K. Schmidt
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA (PHS, KKS, PFM)
- Indiana University Center for Bioethics, Indianapolis, IN, USA (PHS, PFM)
- Philosophy Department, Indiana University School of Liberal Arts, Indianapolis, IN, USA (PHS)
- Indiana University Simon Cancer Center, Indianapolis, IN, USA (PHS, SMP, SMR)
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA (SMP, SA)
| | - Paul F. Muriello
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA (PHS, KKS, PFM)
- Indiana University Center for Bioethics, Indianapolis, IN, USA (PHS, PFM)
- Philosophy Department, Indiana University School of Liberal Arts, Indianapolis, IN, USA (PHS)
- Indiana University Simon Cancer Center, Indianapolis, IN, USA (PHS, SMP, SMR)
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA (SMP, SA)
| | - Sandra Althouse
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA (PHS, KKS, PFM)
- Indiana University Center for Bioethics, Indianapolis, IN, USA (PHS, PFM)
- Philosophy Department, Indiana University School of Liberal Arts, Indianapolis, IN, USA (PHS)
- Indiana University Simon Cancer Center, Indianapolis, IN, USA (PHS, SMP, SMR)
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA (SMP, SA)
| | - Susan M. Rawl
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA (PHS, KKS, PFM)
- Indiana University Center for Bioethics, Indianapolis, IN, USA (PHS, PFM)
- Philosophy Department, Indiana University School of Liberal Arts, Indianapolis, IN, USA (PHS)
- Indiana University Simon Cancer Center, Indianapolis, IN, USA (PHS, SMP, SMR)
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA (SMP, SA)
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Abstract
PURPOSE OF REVIEW Approximately, one quarter of patients discharged after a hospitalization for decompensated cirrhosis will be readmitted within 30 days. These readmissions have been associated with increased morbidity and mortality, can be financially harmful to the health system, and may be partially preventable. This review summarizes the literature on readmissions, providing clinicians with tools for risk prediction and a taxonomy for preventative interventions. RECENT FINDINGS Readmission strategies can be categorized according to complexity (simple versus complex) and specificity (focused versus broad). The literature thus far provides the following generalizable inferences: 1) Interventions should be integrated in the clinical workflow, 2) default options are more powerful than voluntary actions, 3) knowledge improvement should focus on the front line clinicians, 4) process improvements do not always translate into better outcomes, and 5) any successful intervention must include viable alternatives to hospitalization. A growing body of literature provides concrete and actionable guidance for interventions to reduce readmissions in patients with cirrhosis.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology/Hepatology, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Michael Volk
- Division of Gastroenterology/Hepatology and Transplantation Institute, Loma Linda University Health, Loma Linda, CA, USA.
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Machado NR, Anderson SL, Arora VM. In reference to "Pilot study aiming to support sleep quality and duration during hospitalizations". J Hosp Med 2017; 12:61. [PMID: 28125835 DOI: 10.1002/jhm.2681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Nolan R Machado
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Samantha L Anderson
- University of Chicago Medicine, Department of Medicine, Section of General Internal Medicine, Chicago, IL, USA
| | - Vineet M Arora
- University of Chicago Medicine, Department of Medicine, Section of General Internal Medicine, Chicago, IL, USA
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111
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Jotterand F, Amodio A, Elger BS. Patient education as empowerment and self-rebiasing. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2016; 19:553-561. [PMID: 27179973 DOI: 10.1007/s11019-016-9702-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The fiduciary nature of the patient-physician relationship requires clinicians to act in the best interest of their patients. Patients are vulnerable due to their health status and lack of medical knowledge, which makes them dependent on the clinicians' expertise. Competent patients, however, may reject the recommendations of their physician, either refusing beneficial medical interventions or procedures based on their personal views that do not match the perceived medical indication. In some instances, the patients' refusal may jeopardize their health or life but also compromise the clinician's moral responsibility to promote the patient's best interests. In other words, health professionals have to deal with patients whose behavior and healthcare decisions seem counterproductive for their health, or even deteriorate it, because of lack of knowledge, bad habits or bias without being the patients' free voluntary choice. The moral dilemma centers on issues surrounding the limits of the patient's autonomy (rights) and the clinician's role to promote the well-being of the patient (duties). In this paper we argue that (1) the use of manipulative strategies, albeit considered beneficent, defeats the purpose of patient education and therefore should be rejected; and (2) the appropriate strategy is to empower patients through patient education which enhances their autonomy and encourages them to become full healthcare partners as opposed to objects of clinical intervention or entities whose values or attitudes need to be shaped and changed through education. First, we provide a working definition of the concept of patient education and a brief historical overview of its origin. Second, we examine the nature of the patient-physician relationship in order to delineate its boundaries, essential for understanding the role of education in the clinical context. Third, we argue that patient education should promote self-rebiasing, enhance autonomy, and empower patients to determine their therapeutic goals. Finally, we develop a moral framework for patient education.
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Affiliation(s)
- Fabrice Jotterand
- Department of Health Care Ethics, Regis University, Denver, CO, USA.
- Institute of Biomedical Ethics, University of Basel, Basel, Switzerland.
| | | | - Bernice S Elger
- Institute of Biomedical Ethics, University of Basel, Basel, Switzerland
- Center for Legal Medicine, University of Geneva, Geneva, Switzerland
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Aysola J, Tahirovic E, Troxel AB, Asch DA, Gangemi K, Hodlofski AT, Zhu J, Volpp K. A Randomized Controlled Trial of Opt-In Versus Opt-Out Enrollment Into a Diabetes Behavioral Intervention. Am J Health Promot 2016; 32:745-752. [PMID: 28281353 DOI: 10.1177/0890117116671673] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To examine the effect of an opt-out default recruitment strategy compared to a conventional opt-in strategy on enrollment and adherence to a behavioral intervention for poorly controlled diabetic patients. DESIGN Randomized controlled trial. SETTING University of Pennsylvania primary care practices. PARTICIPANTS Participants of this trial included those with (1) age 18 to 80 years; (2) diabetes diagnosis; and (3) a measured hemoglobin A1c (HbA1c) greater than 8% in the past 12 months. INTERVENTION We randomized eligible patients into opt-in and opt-out arms prior to enrollment. Those in the opt-out arm received a letter stating that they were enrolled into a diabetes research study with the option to opt out, and those in the opt-in arm received a standard recruitment letter. MEASURES Main end points include enrollment rate, defined as the proportion of participants who attended the baseline visit, and adherence to daily glycemic monitoring. ANALYSIS We powered our study to detect a 20% difference in adherence to device usage between arms and account for a 10% attrition rate. RESULTS Of the 569 eligible participants who received a recruitment letter, 496 were randomized to the opt-in arm and 73 to the opt-out arm. Enrollment rates were 38% in the opt-out arm and 13% in the opt-in arm ( P < .001). CONCLUSIONS Opt-out defaults, where clinically appropriate, could be a useful approach for increasing the generalizability of low-risk trials testing behavioral interventions in clinical settings.
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Affiliation(s)
- Jaya Aysola
- 1 Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,2 Center for Health Incentives and Behavioral Economics (CHIBE) at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Emin Tahirovic
- 3 Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (CCEB), University of Pennsylvania, Philadelphia, PA, USA
| | - Andrea B Troxel
- 2 Center for Health Incentives and Behavioral Economics (CHIBE) at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,3 Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (CCEB), University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- 1 Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,2 Center for Health Incentives and Behavioral Economics (CHIBE) at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,4 Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA.,5 Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Kelsey Gangemi
- 2 Center for Health Incentives and Behavioral Economics (CHIBE) at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda T Hodlofski
- 2 Center for Health Incentives and Behavioral Economics (CHIBE) at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingsan Zhu
- 2 Center for Health Incentives and Behavioral Economics (CHIBE) at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin Volpp
- 1 Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,2 Center for Health Incentives and Behavioral Economics (CHIBE) at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,4 Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA.,5 Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA.,6 University of Pennsylvania Prevention Research Center, Philadelphia, PA, USA
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113
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Troxel AB, Asch DA, Mehta SJ, Norton L, Taylor D, Calderon TA, Lim R, Zhu J, Kolansky DM, Drachman BM, Volpp KG. Rationale and design of a randomized trial of automated hovering for post-myocardial infarction patients: The HeartStrong program. Am Heart J 2016; 179:166-74. [PMID: 27595692 DOI: 10.1016/j.ahj.2016.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 06/06/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Coronary artery disease is the single leading cause of death in the United States, and medications can significantly reduce the rate of repeat cardiovascular events and treatment procedures. Adherence to these medications, however, is very low. METHODS HeartStrong is a national randomized trial offering 3 innovations. First, the intervention is built on concepts from behavioral economics that we expect to enhance its effectiveness. Second, the implementation of the trial takes advantage of new technology, including wireless pill bottles and remote feedback, to substantially automate procedures. Third, the trial's design includes an enhancement of the standard randomized clinical trial that allows rapid-cycle innovation and ongoing program enhancement. RESULTS Using a system involving direct data feeds from 6 insurance partners followed by mail, telephone, and email contact, we enrolled 1,509 patients discharged from the hospital with acute myocardial infarction in a 2:1 ratio of intervention:usual care. The intervention period lasts 1 year; the primary outcome is time to first fatal or nonfatal acute vascular event or revascularization, including acute myocardial infarction, unstable angina, stroke, acute coronary syndrome admission, or death. CONCLUSIONS Our randomized controlled trial of the HeartStrong program will provide an evaluation of a state-of-the-art behavioral economic intervention with a number of important pragmatic features. These include a tailored intervention responding to patient activity, streamlining of consent and implementation processes using new technologies, outcomes centrally important to patients, and the ability to implement rapid-cycle innovation.
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Affiliation(s)
- Andrea B Troxel
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - David A Asch
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Shivan J Mehta
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Laurie Norton
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Devon Taylor
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Tirza A Calderon
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Raymond Lim
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jingsan Zhu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Daniel M Kolansky
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian M Drachman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kevin G Volpp
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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114
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Predictors of clinicians' underuse of daily sedation interruption and sedation scales. J Crit Care 2016; 38:182-189. [PMID: 27930995 DOI: 10.1016/j.jcrc.2016.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/29/2016] [Accepted: 07/24/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of the study is to identify predictors of underuse of sedation scales and daily sedation interruption (DSI). METHODS We surveyed all physicians and seven nurses in every Belgian intensive care unit (ICU), addressing practices and perceptions on guideline recommendations. Underuse was defined for sedation scales as use less than 3× per day and for DSI as never using it. Classification trees and logistic regressions identified predictors of underuse. RESULTS Underuse of sedation scales and DSI was found for 16.6% and 32.5% of clinicians, respectively. Strongest predictors of underuse of sedation scales were agreeing that using them daily takes much time and being a physician (rather than a nurse). Further predictors were confidence in their ability to measure sedation levels without using scales, for physicians, and nurse/ICU bed ratios less than 1.98, for nurses. The strongest predictor of underuse of DSI among physicians was the perception that DSI impairs patients' comfort. Among nurses, lack of familiarity with DSI, region, and agreeing DSI should only be performed upon medical orders best predicted underuse. CONCLUSIONS Workload considerations hamper utilization of sedation scales. Poor familiarity, for nurses, and negative perception of impact on patients' comfort, for physicians, both reduce DSI utilization. Targeting these obstacles is essential while designing quality improvement strategies to minimize sedative use.
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Courtright KR, Madden V, Gabler NB, Cooney E, Kim J, Herbst N, Burgoon L, Whealdon J, Dember LM, Halpern SD. A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion. Med Decis Making 2016; 37:544-554. [PMID: 27510741 DOI: 10.1177/0272989x16663709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge. OBJECTIVE This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients. METHODOLOGY Outpatients ( N = 316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive either the option to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. Patients in both groups could decline to complete an advance directive or take their selected version home. The primary outcome was a returned, completed advance directive. Secondary outcomes included whether patients wanted to complete an advance directive, decision satisfaction, quality of life at 3 months, and patient factors associated with advance directive completion. RESULTS Although offering more advance directive options was not significantly associated with increased rates of completion (13.1% in the standard group v. 12.2% in the expanded group, P = 0.80), it did significantly increase the proportion of patients who wanted to complete an advance directive and took one home (71.9% in standard v. 85.3% in expanded, P = 0.004). There was no difference in satisfaction ( P = 0.65) or change in quality of life between groups ( P = 0.63). A higher baseline quality of life was independently associated with advance directive completion ( P = 0.006). CONCLUSIONS AND RELEVANCE These results suggest that although an expanded choice set may initially nudge patients toward completing advance directives without restricting choice, increasing actual completion requires additional interventions that overcome downstream barriers.
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Affiliation(s)
- Katherine R Courtright
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, PA (KRC, SDH).,Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH)
| | - Vanessa Madden
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH)
| | - Nicole B Gabler
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH)
| | - Elizabeth Cooney
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH)
| | - Jennifer Kim
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH)
| | - Nicole Herbst
- Department of Medicine, Boston University Medical Center, Boston, MA (NH)
| | - Lauren Burgoon
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH)
| | - Jennifer Whealdon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (JW, SDH)
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA (LMD)
| | - Scott D Halpern
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, PA (KRC, SDH).,Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH).,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (JW, SDH)
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Das BM, Mailey E, Murray K, Phillips SM, Torres C, King AC. From sedentary to active: Shifting the movement paradigm in workplaces. Work 2016; 54:481-7. [DOI: 10.3233/wor-162330] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Bhibha M. Das
- Department of Kinesiology, East Carolina University, Greenville, NC, USA
| | - Emily Mailey
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - Kate Murray
- Department of Family & Preventive Medicine, University of California San Diego, San Diego, CA, USA
| | - Siobhan M. Phillips
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Cam Torres
- We Choose Health Director, Two Rivers YMCA, Moline, IL, USA
| | - Abby C. King
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
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Gabler NB, Cooney E, Small DS, Troxel AB, Arnold RM, White DB, Angus DC, Loewenstein G, Volpp KG, Bryce CL, Halpern SD. Default options in advance directives: study protocol for a randomised clinical trial. BMJ Open 2016; 6:e010628. [PMID: 27266769 PMCID: PMC4908890 DOI: 10.1136/bmjopen-2015-010628] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Although most seriously ill Americans wish to avoid burdensome and aggressive care at the end of life, such care is often provided unless patients or family members specifically request otherwise. Advance directives (ADs) were created to provide opportunities to set limits on aggressive care near life's end. This study tests the hypothesis that redesigning ADs such that comfort-oriented care is provided as the default, rather than requiring patients to actively choose it, will promote better patient-centred outcomes. METHODS AND ANALYSIS This multicentre trial randomises seriously ill adults to receive 1 of 3 different ADs: (1) a traditional AD that requires patients to actively choose their goals of care or preferences for specific interventions (eg, feeding tube insertion) or otherwise have their care guided by their surrogates and the prevailing societal default toward aggressive care; (2) an AD that defaults to life-extending care and receipt of life-sustaining interventions, enabling patients to opt out from such care; or (3) an AD that defaults to comfort care, enabling patients to opt into life-extending care. We seek to enrol 270 patients who return complete, legally valid ADs so as to generate sufficient power to detect differences in the primary outcome of hospital-free days (days alive and not in an acute care facility). Secondary outcomes include hospital and intensive care unit admissions, costs of care, hospice usage, decision conflict and satisfaction, quality of life, concordance of preferences with care received and bereavement outcomes for surrogates of patients who die. ETHICS AND DISSEMINATION This study has been approved by the Institutional Review Boards at all trial centres, and is guided by a data safety and monitoring board and an ethics advisory board. Study results will be disseminated using methods that describe the results in ways that key stakeholders can best understand and implement. TRIAL REGISTRATION NUMBER NCT02017548; Pre-results.
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Affiliation(s)
- Nicole B Gabler
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth Cooney
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dylan S Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrea B Troxel
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Arnold
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - George Loewenstein
- Center for Behavioral Decision Research, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Kevin G Volpp
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cindy L Bryce
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Scott D Halpern
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Audit and feedback interventions to improve endoscopist performance: Principles and effectiveness. Best Pract Res Clin Gastroenterol 2016; 30:473-85. [PMID: 27345652 DOI: 10.1016/j.bpg.2016.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 03/31/2016] [Accepted: 04/07/2016] [Indexed: 01/31/2023]
Abstract
There is considerable variation in the quality of colonoscopy, attributable in part to endoscopist performance. Audit and feedback (A&F) provides health professionals with a summary of their performance over a period of time and is a common strategy used to improve provider performance. In this review, we discuss current understanding of the mechanism of A&F and describe specific features of effective A&F. To date, trials of A&F to improve colonoscopy performance report heterogeneous results, in part because colonoscopy is a complex procedural skill but also because the quality improvement interventions were sub-optimally implemented or inadequately evaluated. Nonetheless, evidence from a wide range of literature suggests that A&F has the potential to improve endoscopist performance. We discuss future directions for research in this area and provide guidance for providers or health system planners wishing to implement A&F to address quality of colonoscopy in their practice and/or jurisdiction.
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Patel MS, Day SC, Halpern SD, Hanson CW, Martinez JR, Honeywell S, Volpp KG. Generic Medication Prescription Rates After Health System-Wide Redesign of Default Options Within the Electronic Health Record. JAMA Intern Med 2016; 176:847-8. [PMID: 27159011 PMCID: PMC7240800 DOI: 10.1001/jamainternmed.2016.1691] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mitesh S Patel
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania2Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Susan C Day
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Scott D Halpern
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - C William Hanson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joseph R Martinez
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Steven Honeywell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kevin G Volpp
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania2Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Bourdeaux CP, Thomas MJC, Gould TH, Malhotra G, Jarvstad A, Jones T, Gilchrist ID. Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses. BMJ Open 2016; 6:e010129. [PMID: 27230998 PMCID: PMC4885280 DOI: 10.1136/bmjopen-2015-010129] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Low tidal volume (TVe) ventilation improves outcomes for ventilated patients, and the majority of clinicians state they implement it. Unfortunately, most patients never receive low TVes. 'Nudges' influence decision-making with subtle cognitive mechanisms and are effective in many contexts. There have been few studies examining their impact on clinical decision-making. We investigated the impact of 2 interventions designed using principles from behavioural science on the deployment of low TVe ventilation in the intensive care unit (ICU). SETTING University Hospitals Bristol, a tertiary, mixed medical and surgical ICU with 20 beds, admitting over 1300 patients per year. PARTICIPANTS Data were collected from 2144 consecutive patients receiving controlled mechanical ventilation for more than 1 hour between October 2010 and September 2014. Patients on controlled mechanical ventilation for more than 20 hours were included in the final analysis. INTERVENTIONS (1) Default ventilator settings were adjusted to comply with low TVe targets from the initiation of ventilation unless actively changed by a clinician. (2) A large dashboard was deployed displaying TVes in the format mL/kg ideal body weight (IBW) with alerts when TVes were excessive. PRIMARY OUTCOME MEASURE TVe in mL/kg IBW. FINDINGS TVe was significantly lower in the defaults group. In the dashboard intervention, TVe fell more quickly and by a greater amount after a TVe of 8 mL/kg IBW was breached when compared with controls. This effect improved in each subsequent year for 3 years. CONCLUSIONS This study has demonstrated that adjustment of default ventilator settings and a dashboard with alerts for excessive TVe can significantly influence clinical decision-making. This offers a promising strategy to improve compliance with low TVe ventilation, and suggests that using insights from behavioural science has potential to improve the translation of evidence into practice.
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Affiliation(s)
| | | | - Timothy H Gould
- Intensive Care Unit, University Hospitals Bristol, Bristol, UK
| | - Gaurav Malhotra
- School of Experimental Psychology, University of Bristol, Bristol, UK
| | - Andreas Jarvstad
- School of Experimental Psychology, University of Bristol, Bristol, UK
| | | | - Iain D Gilchrist
- School of Experimental Psychology, University of Bristol, Bristol, UK
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121
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Using active choice within the electronic health record to increase physician ordering and patient completion of high-value cancer screening tests. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2016; 4:340-345. [PMID: 28007228 DOI: 10.1016/j.hjdsi.2016.04.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND High value screening tests such as colonoscopy and mammography can improve early cancer detection but are often underutilized. METHODS We evaluated an active choice intervention using the electronic health record (EHR) to confirm patient eligibility for colonoscopy or mammography during the patient's clinic visit and prompt the physician and his/her medical assistant to actively choose to "accept" or "cancel" an order for it. We fit multivariate logistic regression models using a difference-in-differences approach to evaluate changes in physician ordering and patient completion of colonoscopy and mammography at the intervention practice compared to two control practices, adjusting for time trends, patient and clinic visit characteristics. RESULTS The sample comprised 7560 patients due for colonoscopy and 8337 patients due for mammography. Pre-intervention trends between practices did not differ. In the adjusted models, compared to the control group over time, the intervention practice had a significant increase in ordering of colonoscopy (11.8% points, 95% CI: 8.0-15.6, P<0.001) and mammography (12.4% points, 95% CI: 8.7-16.2, P<0.001). There was a significant increase in patient completion of colonoscopy (3.5% points, 95% CI: 1.1-5.9, P<0.01), but no change in mammography (2.2% points, 95% CI: -1.0 to 5.5, P=0.18). CONCLUSIONS Active choice through the EHR was associated with an increase in physician ordering of colonoscopy and mammography. The intervention was also associated with an increase in patient completion of colonoscopy but no change in patient completion of mammography.
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123
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Anesi GL, Halpern SD. Choice architecture in code status discussions with terminally ill patients and their families. Intensive Care Med 2016; 42:1065-7. [PMID: 26951425 DOI: 10.1007/s00134-016-4294-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 02/24/2016] [Indexed: 11/30/2022]
Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, 726 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, Philadelphia, USA
| | - Scott D Halpern
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, 726 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA. .,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. .,Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, Philadelphia, USA. .,Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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124
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Ojerholm E, Halpern SD, Bekelman JE. Default Options: Opportunities to Improve Quality and Value in Oncology. J Clin Oncol 2016; 34:1844-7. [PMID: 26884581 DOI: 10.1200/jco.2015.64.8741] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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125
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Lehmann BA, Chapman GB, Franssen FME, Kok G, Ruiter RAC. Changing the default to promote influenza vaccination among health care workers. Vaccine 2016; 34:1389-92. [PMID: 26851734 DOI: 10.1016/j.vaccine.2016.01.046] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/15/2016] [Accepted: 01/20/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The prevention of health care acquired infections is an important objective for patient safety and infection control in all health care settings. Influenza vaccination uptake among health care workers (HCWs) is the most effective method to prevent transmission to patients, but vaccination coverage rates are low among HCWs. Several educational campaigns have been developed to increase the influenza vaccination coverage rates of HCWs, but showed only small effects. The aim of this study was to test an opt-out strategy in promoting uptake among HCWs in a tertiary care center for patients with complex chronic organ failure. METHODS HCWs were randomly assigned to one of two conditions. In the opt-out condition (N=61), participants received an e-mail with a pre-scheduled appointment for influenza vaccination, which could be changed or canceled. In the opt-in condition (N=61), participants received an e-mail explaining that they had to schedule an appointment if they wanted to get vaccinated. RESULTS The findings show no statistically detectable effect of condition on being vaccinated against influenza. However, HCWs in the opt-out condition were more likely to have an appointment for influenza vaccination, which in turn increased the probability of getting vaccinated. CONCLUSION To change the default to promote influenza vaccination among HCWs might be an easy and cost-effective alternative to the complex vaccination campaigns that have been proposed in recent years.
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Affiliation(s)
- Birthe A Lehmann
- Center for Infectious Disease Control, Epidemiology and Surveillance, National Institute for Public Health and the Environment (RIVM), PO Box 1, Bilthoven, BA 3720, The Netherlands.
| | - Gretchen B Chapman
- Department of Psychology, Rutgers University, 152 Frelinghuysen Road, Piscataway, NJ 08854-8020, USA.
| | - Frits M E Franssen
- CIRO+, Centre of Expertise for Chronic Organ Failure, Hornerheide 1, Horn, NM 6085, The Netherlands.
| | - Gerjo Kok
- Department of Work & Social Psychology, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, Maastricht, MD 6200, The Netherlands.
| | - Robert A C Ruiter
- Department of Work & Social Psychology, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, Maastricht, MD 6200, The Netherlands.
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Peters J, Beck J, Lande J, Pan Z, Cardel M, Ayoob K, Hill JO. Using Healthy Defaults in Walt Disney World Restaurants to Improve Nutritional Choices. JOURNAL OF THE ASSOCIATION FOR CONSUMER RESEARCH 2016; 1:92-103. [PMID: 30417105 PMCID: PMC6223634 DOI: 10.1086/684364] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A retrospective study of kids' meals purchased at Walt Disney World was conducted to determine acceptance rates for healthy sides and beverages. Purchase data from all 145 Walt Disney World restaurants were analyzed using a log-linear model and a Poisson regression. Across all restaurants, 47.9% and 66.3% of guests accepted healthy default sides and beverages, respectively. Acceptance rates of sides and beverages were higher at quick-service restaurants (49.4% and 67.8%, respectively) compared to table-service restaurants (40.3% and 45.6%, respectively). The healthy defaults reduced calories (21.4%), fat (43.9%), and sodium (43.4%) for kids' meal sides and beverages. This study contributes by examining the use of kids' meal healthy defaults in quick-service and table-service restaurant formats at the world's largest theme park, a previously unstudied setting, and by providing the largest ever healthy default data set. The results suggest that healthy defaults can shift food and beverage selection patterns toward healthier options.
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Affiliation(s)
- John Peters
- Professor, Anschutz Health and Wellness Center, University of Colorado, Anschutz Medical Campus, 12348 E. Montview Blvd., Mailbox C263, Aurora, CO 80045
| | - Jimikaye Beck
- Professional research assistant, Anschutz Health and Wellness Center, University of Colorado, Anschutz Medical Campus, 12348 E. Montview Blvd., Mailbox C263, Aurora, CO 80045
| | - Jan Lande
- Professional research assistant, Anschutz Health and Wellness Center, University of Colorado, Anschutz Medical Campus, 12348 E. Montview Blvd., Mailbox C263, Aurora, CO 80045
| | - Zhaoxing Pan
- Associate professor, Department of Pediatrics, 13001 E. 17th Place, B119, Aurora, CO 80045
| | - Michelle Cardel
- Assistant professor, Department of Outcomes and Policy, University of Florida, 1329 SW 16th Street, Gainseville, FL 32608
| | - Keith Ayoob
- Associate clinical professor, Department of Pediatrics, Albert Einstein College of Medicine of Yeshiva University, Louis and Dora Rousso Building, 1165 Morris Park Ave., Room 438, Bronx, NY 10461
| | - James O Hill
- Professor, Anschutz Health and Wellness Center, University of Colorado, Anschutz Medical Campus, 12348 E. Montview Blvd., Mailbox C263, Aurora, CO 80045
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Kon AA, Davidson JE, Morrison W, Danis M, White DB. Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med 2016; 44:188-201. [PMID: 26509317 PMCID: PMC4788386 DOI: 10.1097/ccm.0000000000001396] [Citation(s) in RCA: 313] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Shared decision making is endorsed by critical care organizations; however, there remains confusion about what shared decision making is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define shared decision making, recommend when shared decision making should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. DESIGN The American College of Critical Care Medicine and American Thoracic Society Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of American College of Critical Care Medicine and American Thoracic Society were included in the statement. MAIN RESULTS Six recommendations were endorsed: 1) DEFINITION: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences. 2) Clinicians should engage in a shared decision making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their "default" approach a shared decision making process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. CONCLUSIONS Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.
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Affiliation(s)
- Alexander A. Kon
- Naval Medical Center San Diego, San Diego, CA
- University of California San Diego, San Diego, CA
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Smith WR. Diagnostic Reference Levels as They Are or as They Should Be: A Reply to Miller, Vano, and Rehani. J Am Coll Radiol 2015; 12:1008-9. [DOI: 10.1016/j.jacr.2015.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
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Münscher R, Vetter M, Scheuerle T. A Review and Taxonomy of Choice Architecture Techniques. JOURNAL OF BEHAVIORAL DECISION MAKING 2015. [DOI: 10.1002/bdm.1897] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Robert Münscher
- Centre for Social Investment; Heidelberg University; Heidelberg Germany
| | - Max Vetter
- Centre for Social Investment; Heidelberg University; Heidelberg Germany
| | - Thomas Scheuerle
- Centre for Social Investment; Heidelberg University; Heidelberg Germany
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Abstract
This article reviews the ethics of rhetoric in critical care. Rational appeals in critical care fail to move patients or surrogates to a better course of action. Appeals to their emotions are considered illegitimate because they may preclude autonomous choice. This article discusses whether it is always unethical to change someone's beliefs, whether persuasive communication is inherently harmful and whether it leaves no space for voluntariness. To answer these questions, the article engages with Aristotle's work, Rhetoric. In considering whether there is a place for emotionally charged messages in a patient-provider relationship, the article intends to delineate the nature of this relationship and describe the duties this relationship implies. The article presents examples of persuasive communication used in critical care and discusses whether providers may have a duty to persuade patients. This duty is supported by the fact that doctors often influence patients' and families' choices by framing presented options. Doctors should assume responsibility in recognizing these personal and contextual influences that may influence the medical choices of their patients. They should attempt to modify these contextual factors and biases in a way that would assist patients and families in reaching the desired outcomes. The opening sections surveyed a number of definitions found in relevant literature and outlined some of the concepts included in the proposed definition. This definition helps to distinguish instances of persuasion from cases of manipulation, coercion and deception. Considering the fact that patients and families often make irrational decisions and the fact that doctors inadvertently influence their choices, the article suggested that persuasion can be a positive tool in medical communication. When patients or families clearly do not understand the risks or make decisions that contradict their long-term goals, persuasion can be used as a positive influence.
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Affiliation(s)
- Alex Dubov
- Center for Healthcare Ethics, Duquesne University, Pittsburgh, PA, USA; Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA; Florida Hospital Celebration Health, Celebration, FL, USA
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Needham DM, Yang T, Dinglas VD, Mendez-Tellez PA, Shanholtz C, Sevransky JE, Brower RG, Pronovost PJ, Colantuoni E. Timing of low tidal volume ventilation and intensive care unit mortality in acute respiratory distress syndrome. A prospective cohort study. Am J Respir Crit Care Med 2015; 191:177-85. [PMID: 25478681 DOI: 10.1164/rccm.201409-1598oc] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Reducing tidal volume decreases mortality in acute respiratory distress syndrome (ARDS). However, the effect of the timing of low tidal volume ventilation is not well understood. OBJECTIVES To evaluate the association of intensive care unit (ICU) mortality with initial tidal volume and with tidal volume change over time. METHODS Multivariable, time-varying Cox regression analysis of a multisite, prospective study of 482 patients with ARDS with 11,558 twice-daily tidal volume assessments (evaluated in milliliter per kilogram of predicted body weight [PBW]) and daily assessment of other mortality predictors. MEASUREMENTS AND MAIN RESULTS An increase of 1 ml/kg PBW in initial tidal volume was associated with a 23% increase in ICU mortality risk (adjusted hazard ratio, 1.23; 95% confidence interval [CI], 1.06-1.44; P = 0.008). Moreover, a 1 ml/kg PBW increase in subsequent tidal volumes compared with the initial tidal volume was associated with a 15% increase in mortality risk (adjusted hazard ratio, 1.15; 95% CI, 1.02-1.29; P = 0.019). Compared with a prototypical patient receiving 8 days with a tidal volume of 6 ml/kg PBW, the absolute increase in ICU mortality (95% CI) of receiving 10 and 8 ml/kg PBW, respectively, across all 8 days was 7.2% (3.0-13.0%) and 2.7% (1.2-4.6%). In scenarios with variation in tidal volume over the 8-day period, mortality was higher when a larger volume was used earlier. CONCLUSIONS Higher tidal volumes shortly after ARDS onset were associated with a greater risk of ICU mortality compared with subsequent tidal volumes. Timely recognition of ARDS and adherence to low tidal volume ventilation is important for reducing mortality. Clinical trial registered with www.clinicaltrials.gov (NCT 00300248).
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Abstract
Modern medicine has transformed the dying experience. In the developed world, most of us no longer die from infectious diseases and sudden accidents, but from chronic illnesses that progressively worsen. Yet the U.S. healthcare system is not designed to meet the needs of people with chronic illness or of frail elders. In addition, our system incentivizes the use of technologies that are often helpful when an underlying condition is reversible but, when used very near the end of life, may only postpone the dying process and increase burdens on the patient. This state of affairs renders many people near the end of life without adequate symptom control, little or no social and psychological support, and inadequate involvement in decisions about when and how best to use modern technologies. This paper traces efforts over the last three decades to address problems related to modern dying. The author sees three phases: early work focused on securing patients' rights to refuse unwanted treatments, the next phase focused on building the specialty of palliative medicine, and the third and future phase must redesign our healthcare system to better align with how we die in the 21st century.
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Affiliation(s)
- Mildred Z Solomon
- The Hastings Center, Garrison, New York; Harvard Medical School, Boston, Massachusetts
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133
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Vlaev I, Dolan P. Action Change Theory: A Reinforcement Learning Perspective on Behavior Change. REVIEW OF GENERAL PSYCHOLOGY 2015. [DOI: 10.1037/gpr0000029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Ivo Vlaev
- Warwick Business School, University of Warwick
| | - Paul Dolan
- Department of Social Policy, London School of Economics
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Tannenbaum D, Doctor JN, Persell SD, Friedberg MW, Meeker D, Friesema EM, Goldstein NJ, Linder JA, Fox CR. Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study. J Gen Intern Med 2015; 30:298-304. [PMID: 25394536 PMCID: PMC4351289 DOI: 10.1007/s11606-014-3051-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 07/28/2014] [Accepted: 09/09/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can influence provider decisions for better or worse. OBJECTIVE The purpose of this study was to examine whether the grouping of menu items systematically affects prescribing practices among primary care providers. PARTICIPANTS We surveyed 166 primary care providers in a research network of practices in the greater Chicago area, of whom 84 responded (51% response rate). Respondents and non-respondents were similar on all observable dimensions except that respondents were more likely to work in an academic setting. DESIGN The questionnaire consisted of seven clinical vignettes. Each vignette described typical signs and symptoms for acute respiratory infections, and providers chose treatments from a menu of options. For each vignette, providers were randomly assigned to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either listed over-the-counter (OTC) medications individually while grouping prescriptions together, or displayed the reverse partition. For antibiotic-appropriate vignettes, the treatment menu either listed narrow-spectrum antibiotics individually while grouping broad-spectrum antibiotics, or displayed the reverse partition. MAIN MEASURES The main outcome was provider treatment choice. For antibiotic-inappropriate vignettes, we categorized responses as prescription drugs or OTC-only options. For antibiotic-appropriate vignettes, we categorized responses as broad- or narrow-spectrum antibiotics. KEY RESULTS Across vignettes, there was an 11.5 percentage point reduction in choosing aggressive treatment options (e.g., broad-spectrum antibiotics) when aggressive options were grouped compared to when those same options were listed individually (95% CI: 2.9 to 20.1%; p = .008). CONCLUSIONS Provider treatment choice appears to be influenced by the grouping of menu options, suggesting that the layout of EHR order sets is not an arbitrary exercise. The careful crafting of EHR order sets can serve as an important opportunity to improve patient care without constraining physicians' ability to prescribe what they believe is best for their patients.
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Affiliation(s)
- David Tannenbaum
- UCLA Anderson School of Management, 110 Westwood Plaza D-501, Los Angeles, CA, 90095, USA,
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135
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Halpern SD, Emanuel EJ. Ethical guidance on the use of life-sustaining therapies for patients with Ebola in developed countries. Ann Intern Med 2015; 162:304-5. [PMID: 25545099 DOI: 10.7326/m14-2611] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Scott D. Halpern
- From the Leonard Davis Institute of Health Economics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ezekiel J. Emanuel
- From the Leonard Davis Institute of Health Economics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
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136
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Will Choosing Wisely® improve quality and lower costs of care for patients with critical illness? Ann Am Thorac Soc 2015; 11:823-7. [PMID: 24762102 DOI: 10.1513/annalsats.201403-093oi] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
In 2009, a group of experts convened by the Institute of Medicine estimated that 30% of health care costs amounted to waste, including a substantial share from nonbeneficial and often harmful services. Professional organizations and medical ethicists subsequently called on specialty groups to generate "top five" lists of expensive tests or treatments without known benefits. Responding to this call, the American Board of Internal Medicine launched its Choosing Wisely campaign, with the top-five Choosing Wisely lists for pulmonary medicine and critical care released in 2014. In order for the critical care list to have an impact on costs and quality, two things must occur: providers whose practice is discordant with the list must adhere to the list when making decisions, and those decisions must lead to improvements in the quality of care at lower costs. Although the campaign addresses some limitations of past efforts to improve quality and reduce waste, we believe it will do little to change provider behavior. Even if the top-five list for critical care were to change the behavior of providers, its ultimate impact on costs and quality will be lower than anticipated. Here we suggest several strategies for stakeholders to increase the impact of the critical care top-five list, and further discuss that despite limitations of the campaign it is still imperative for advancing best practice in critical care.
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Blumenthal-Barby JS, McGuire AL, Green RC, Ubel PA. How behavioral economics can help to avoid 'The last mile problem' in whole genome sequencing. Genome Med 2015; 7:3. [PMID: 25614766 PMCID: PMC4302430 DOI: 10.1186/s13073-015-0132-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Failure to consider lessons from behavioral economics in the case of whole genome sequencing may cause us to run into the 'last mile problem' - the failure to integrate newly developed technology, on which billions of dollars have been invested, into society in a way that improves human behavior and decision-making.
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Affiliation(s)
- Jennifer S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza MS 420, Houston, TX 77030 USA
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza MS 420, Houston, TX 77030 USA
| | - Robert C Green
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Avenue Louis Pasteur, Boston, MA 02115 USA
| | - Peter A Ubel
- Fuqua School of Business and Sanford School of Public Policy, Duke University, Fuqua Drive, Durham, NC 27708 USA
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138
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Purnell JQ, Thompson T, Kreuter MW, McBride TD. Behavioral economics: "nudging" underserved populations to be screened for cancer. Prev Chronic Dis 2015; 12:E06. [PMID: 25590600 PMCID: PMC4307834 DOI: 10.5888/pcd12.140346] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Persistent disparities in cancer screening by race/ethnicity and socioeconomic status require innovative prevention tools and techniques. Behavioral economics provides tools to potentially reduce disparities by informing strategies and systems to increase prevention of breast, cervical, and colorectal cancers. With an emphasis on the predictable, but sometimes flawed, mental shortcuts (heuristics) people use to make decisions, behavioral economics offers insights that practitioners can use to enhance evidence-based cancer screening interventions that rely on judgments about the probability of developing and detecting cancer, decisions about competing screening options, and the optimal presentation of complex choices (choice architecture). In the area of judgment, we describe ways practitioners can use the availability and representativeness of heuristics and the tendency toward unrealistic optimism to increase perceptions of risk and highlight benefits of screening. We describe how several behavioral economic principles involved in decision-making can influence screening attitudes, including how framing and context effects can be manipulated to highlight personally salient features of cancer screening tests. Finally, we offer suggestions about ways practitioners can apply principles related to choice architecture to health care systems in which cancer screening takes place. These recommendations include the use of incentives to increase screening, introduction of default options, appropriate feedback throughout the decision-making and behavior completion process, and clear presentation of complex choices, particularly in the context of colorectal cancer screening. We conclude by noting gaps in knowledge and propose future research questions to guide this promising area of research and practice.
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Affiliation(s)
- Jason Q Purnell
- The Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130. E-mail:
| | - Tess Thompson
- Washington University in St. Louis, St. Louis, Missouri
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Abstract
The majority of preventable diseases in both developed and developing countries could be strategically controlled by effectively implementing existing health promotion and disease prevention (HPDP) interventions. An important juncture for the implementation of risk-reduction strategies is the point of interaction between health care providers and patients during their scheduled visits. This article targets strategies for physicians to effectively implement HPDP interventions in a clinical setting. The factors that improve delivery of HPDP interventions are discussed briefly. We subsequently introduce and discuss the conceptual framework for enhanced patient education, which is based on the information-motivation-behavioral skills model and the health belief model. The article also describes an adapted patient-practitioner collaborative model for HPDP. This adapted model may serve as a blueprint for physicians to effectively execute HPDP interventions during clinical encounters. The recommended models and our conceptual frameworks could have limitations which need to be field tested.
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140
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Forman EM, Butryn ML. A new look at the science of weight control: how acceptance and commitment strategies can address the challenge of self-regulation. Appetite 2015; 84:171-80. [PMID: 25445199 PMCID: PMC4314333 DOI: 10.1016/j.appet.2014.10.004] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 08/09/2014] [Accepted: 10/02/2014] [Indexed: 11/28/2022]
Abstract
The current manuscript proposes an acceptance-based, self-regulation framework for understanding the challenge of weight maintenance and describes how this framework can be integrated into the behavioral treatment of obesity. According to this framework, intrinsic drives to consume palatable, high-calorie food interact with a modern environment in which high calorie foods are easily accessible. This combination produces a chronic desire to eat unhealthy foods that exists in opposition to individuals' weight control goals. Similarly, low energy expenditure requirements reduce physical activity. We suggest that individuals vary in their responsivity to cues that motivate overeating and sedentary behavior, and that those higher in responsivity need specialized self-regulatory skills to maintain healthy eating and exercise behaviors. These skills include an ability to tolerate uncomfortable internal reactions to triggers and a reduction of pleasure, behavioral commitment to clearly-defined values, and metacognitive awareness of decision-making processes. So-called "acceptance-based" interventions based on these skills have so far proven efficacious for weight control, especially for those who are the most susceptible to eating in response to internal and external cues (as predicted by the model). Despite the current empirical support for the postulated model, much remains to be learned including whether acceptance-based interventions will prove efficacious in the longer-term.
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Abstract
PURPOSE OF REVIEW Default options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology. RECENT FINDINGS Defaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking. SUMMARY Defaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.
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Affiliation(s)
- Joanna Hart
- Division of Pulmonary, Allergy and Critical Care Medicine, Leonard Davis Institute of Health Economics and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott D. Halpern
- Division of Pulmonary, Allergy and Critical Care Medicine, Leonard Davis Institute of Health Economics and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Epidemiology and Biostatistics and Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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143
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Otten JJ, Saelens BE, Kapphahn KI, Hekler EB, Buman MP, Goldstein BA, Krukowski RA, O'Donohue LS, Gardner CD, King AC. Impact of San Francisco's toy ordinance on restaurants and children's food purchases, 2011-2012. Prev Chronic Dis 2014; 11:E122. [PMID: 25032837 PMCID: PMC4110247 DOI: 10.5888/pcd11.140026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction In 2011, San Francisco passed the first citywide ordinance to improve the nutritional standards of children’s meals sold at restaurants by preventing the giving away of free toys or other incentives with meals unless nutritional criteria were met. This study examined the impact of the Healthy Food Incentives Ordinance at ordinance-affected restaurants on restaurant response (eg, toy-distribution practices, change in children’s menus), and the energy and nutrient content of all orders and children’s-meal–only orders purchased for children aged 0 through 12 years. Methods Restaurant responses were examined from January 2010 through March 2012. Parent–caregiver/child dyads (n = 762) who were restaurant customers were surveyed at 2 points before and 1 seasonally matched point after ordinance enactment at Chain A and B restaurants (n = 30) in 2011 and 2012. Results Both restaurant chains responded to the ordinance by selling toys separately from children’s meals, but neither changed their menus to meet ordinance-specified nutrition criteria. Among children for whom children’s meals were purchased, significant decreases in kilocalories, sodium, and fat per order were likely due to changes in children’s side dishes and beverages at Chain A. Conclusion Although the changes at Chain A did not appear to be directly in response to the ordinance, the transition to a more healthful beverage and default side dish was consistent with the intent of the ordinance. Study results underscore the importance of policy wording, support the concept that more healthful defaults may be a powerful approach for improving dietary intake, and suggest that public policies may contribute to positive restaurant changes.
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Affiliation(s)
- Jennifer J Otten
- University of Washington School of Public Health, Nutritional Sciences Program, Box 353410, Seattle, WA 98115. E-mail:
| | - Brian E Saelens
- University of Washington and Seattle Children's Research Institute, Seattle, Washington
| | | | - Eric B Hekler
- School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona
| | - Matthew P Buman
- School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona
| | | | | | | | | | - Abby C King
- Stanford University School of Medicine, Stanford, California
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144
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Aggarwal A, Davies J, Sullivan R. "Nudge" in the clinical consultation--an acceptable form of medical paternalism? BMC Med Ethics 2014; 15:31. [PMID: 24742113 PMCID: PMC4005908 DOI: 10.1186/1472-6939-15-31] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 04/11/2014] [Indexed: 11/23/2022] Open
Abstract
Background Libertarian paternalism is a concept derived from cognitive psychology and behavioural science. It is behind policies that frame information in such a way as to encourage individuals to make choices which are in their best interests, while maintaining their freedom of choice. Clinicians may view their clinical consultations as far removed from the realms of cognitive psychology but on closer examination there are a number of striking similarities. Discussion Evidence has shown that decision making is prone to bias and not necessarily rational or logical, particularly during ill health. Clinicians will usually have an opinion about what course of action represents the patient’s best interests and thus may “frame” information in a way which “nudges” patients into making choices which are considered likely to maximise their welfare. This may be viewed as interfering with patient autonomy and constitute medical paternalism and appear in direct opposition to the tenets of modern practice. However, we argue that clinicians have a responsibility to try and correct “reasoning failure” in patients. Some compromise between patient autonomy and medical paternalism is justified on these grounds and transparency of how these techniques may be used should be promoted. Summary Overall the extremes of autonomy and paternalism are not compatible in a responsive, responsible and moral health care environment, and thus some compromise of these values is unavoidable. Nudge techniques are widely used in policy making and we demonstrate how they can be applied in shared medical decision making. Whether or not this is ethically sound is a matter of continued debate but health care professionals cannot avoid the fact they are likely to be using nudge within clinical consultations. Acknowledgment of this will lead to greater self-awareness, reflection and provide further avenues for debate on the art and science of clinical communication.
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Affiliation(s)
- Ajay Aggarwal
- Department of Research Oncology, King's Institute of Cancer Policy, Guys Hospital, 3rd Floor Bermondsey Wing, Great Maze Pond, London SE1 9RT, England.
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145
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Abhyankar P, Summers BA, Velikova G, Bekker HL. Framing Options as Choice or Opportunity. Med Decis Making 2014; 34:567-82. [DOI: 10.1177/0272989x14529624] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/28/2014] [Indexed: 11/15/2022]
Abstract
Objective. Health professionals must enable patients to make informed decisions about health care choices through unbiased presentation of all options. This study examined whether presenting the decision as “opportunity” rather than “choice” biased individuals’ preferences in the context of trial participation for cancer treatment. Methods. Self-selecting healthy women ( N = 124) were randomly assigned to the following decision frames: opportunity to take part in the trial (opt-in), opportunity to be removed from the trial (opt-out), and choice to have standard treatment or take part in the trial (choice). The computer-based task required women to make a hypothetical choice about a real-world cancer treatment trial. The software presented the framed scenario, recorded initial preference, presented comprehensive and balanced information, traced participants’ use of information during decision making, and recorded final decision. A posttask paper questionnaire assessed perceived risk, attitudes, subjective norm, perceived behavioral control, and satisfaction with decision. Results. Framing influenced women’s immediate preferences. Opportunity frames, whether opt-in or opt-out, introduced a bias as they discouraged women from choosing standard treatment. Using the choice frame avoided this bias. The opt-out opportunity frame also affected women’s perceived social norm; women felt that others endorsed the trial option. The framing bias was not present once participants had had the opportunity to view detailed information on the options within a patient decision aid format. There were no group differences in information acquisition and final decisions. Sixteen percent changed their initial preference after receiving full information. Conclusions. A “choice” frame, where all treatment options are explicit, is less likely to bias preferences. Presentation of full information in parallel, option-by-attribute format is likely to “de-bias” the decision frame. Tailoring of information to initial preferences would be ill-advised as preferences may change following detailed information.
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Affiliation(s)
- Purva Abhyankar
- Leeds Institute of Health Sciences, University of Leeds, UK (PA)
- Centre for Decision Research, Leeds University Business School, UK (BAS)
- Leeds Institute for Molecular Medicine, St. James’s Institute of Oncology, University of Leeds, UK (GV)
- Leeds Institute of Health Sciences, University of Leeds, UK (HLB)
| | - Barbara A. Summers
- Leeds Institute of Health Sciences, University of Leeds, UK (PA)
- Centre for Decision Research, Leeds University Business School, UK (BAS)
- Leeds Institute for Molecular Medicine, St. James’s Institute of Oncology, University of Leeds, UK (GV)
- Leeds Institute of Health Sciences, University of Leeds, UK (HLB)
| | - Galina Velikova
- Leeds Institute of Health Sciences, University of Leeds, UK (PA)
- Centre for Decision Research, Leeds University Business School, UK (BAS)
- Leeds Institute for Molecular Medicine, St. James’s Institute of Oncology, University of Leeds, UK (GV)
- Leeds Institute of Health Sciences, University of Leeds, UK (HLB)
| | - Hilary L. Bekker
- Leeds Institute of Health Sciences, University of Leeds, UK (PA)
- Centre for Decision Research, Leeds University Business School, UK (BAS)
- Leeds Institute for Molecular Medicine, St. James’s Institute of Oncology, University of Leeds, UK (GV)
- Leeds Institute of Health Sciences, University of Leeds, UK (HLB)
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Volpp KG. The Counseling African Americans to Control Hypertension study and ways to enhance the next wave of behavioral interventions. Circulation 2014; 129:2002-4. [PMID: 24657990 DOI: 10.1161/circulationaha.114.009409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Kevin G Volpp
- From the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; Perelman School of Medicine, Wharton School, and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA.
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147
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Everett JN, Gustafson SL, Raymond VM. Traditional roles in a non-traditional setting: genetic counseling in precision oncology. J Genet Couns 2014; 23:655-60. [PMID: 24578120 DOI: 10.1007/s10897-014-9698-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 01/31/2014] [Indexed: 02/06/2023]
Abstract
Next generation sequencing technology is increasingly utilized in oncology with the goal of targeting therapeutics to improve response and reduce side effects. Interpretation of tumor mutations requires sequencing of paired germline DNA, raising questions about incidental germline findings. We describe our experiences as part of a research team implementing a protocol for whole genome sequencing (WGS) of tumors and paired germline DNA known as the Michigan Oncology Sequencing project (MI-ONCOSEQ) that includes options for receiving incidental germline findings. Genetic counselors (GCs) discuss options for return of results with patients during the informed consent process and document family histories. GCs also review germline findings and actively participate in the multi-disciplinary Precision Medicine Tumor Board (PMTB), providing clinical context for interpretation of germline results and making recommendations about disclosure of germline findings. GCs have encountered ethical and counseling challenges with participants, described here. Although GCs have not been traditionally involved in molecular testing of tumors, our experiences with MI-ONCOSEQ demonstrate that GCs have important applicable skills to contribute to multi-disciplinary care teams implementing precision oncology. Broader use of WGS in oncology treatment decision making and American College of Medical Genetics and Genomics (ACMG) recommendations for active interrogation of germline tissue in tumor-normal dyads suggests that GCs will have future opportunities in this area outside of research settings.
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Affiliation(s)
- Jessica N Everett
- Department of Internal Medicine, University of Michigan, 300 North Ingalls, NI3A16, Ann Arbor, MI, 48109, USA,
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Bruce CR, Fetter JE, Blumenthal-Barby JS. Cascade effects in critical care medicine: a call for practice changes. Am J Respir Crit Care Med 2014; 188:1384-5. [PMID: 24328766 DOI: 10.1164/rccm.201309-1606ed] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Courtenay R Bruce
- 1 Center for Medical Ethics and Health Policy Baylor College of Medicine Houston, Texas and Houston Methodist Hospital System Houston Methodist Hospital System Biomedical Ethics Program Houston, Texas
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King D, Greaves F, Vlaev I, Darzi A. Approaches based on behavioral economics could help nudge patients and providers toward lower health spending growth. Health Aff (Millwood) 2014; 32:661-8. [PMID: 23569045 DOI: 10.1377/hlthaff.2012.1348] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Policies that change the environment or context in which decisions are made and "nudge" people toward particular choices have been relatively ignored in health care. This article examines the role that approaches based on behavioral economics could play in "nudging" providers and patients in ways that could slow health care spending growth. The basic insight of behavioral economics is that behavior is guided by the very fallible human brain and greatly influenced by the environment or context in which choices are made. In policy arenas such as pensions and personal savings, approaches based on behavioral economics have provided notable results. In health care, such approaches have been used successfully but in limited ways, as in the use of surgical checklists that have increased patient safety and reduced costs. With health care spending climbing at unsustainable rates, we review the role that approaches based on behavioral economics could play in offering policy makers a potential set of new tools to slow spending growth.
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150
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Courtney MR, Spivey C, Daniel KM. Helping patients make better decisions: how to apply behavioral economics in clinical practice. Patient Prefer Adherence 2014; 8:1503-12. [PMID: 25378915 PMCID: PMC4219638 DOI: 10.2147/ppa.s71224] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Clinicians are committed to effectively educating patients and helping them to make sound decisions concerning their own health care. However, how do clinicians determine what is effective education? How do they present information clearly and in a manner that patients understand and can use to make informed decisions? Behavioral economics (BE) is a subfield of economics that can assist clinicians to better understand how individuals actually make decisions. BE research can help guide interactions with patients so that information is presented and discussed in a more deliberate and impactful way. We can be more effective providers of care when we understand the factors that influence how our patients make decisions, factors of which we may have been largely unaware. BE research that focuses on health care and medical decision making is becoming more widely known, and what has been reported suggests that BE interventions can be effective in the medical realm. The purpose of this article is to provide clinicians with an overview of BE decision science and derived practice strategies to promote more effective behavior change in patients.
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Affiliation(s)
- Maureen Reni Courtney
- College of Nursing, University of Texas at Arlington, Arlington, TX, USA
- Correspondence: Maureen Reni Courtney, College of Nursing, University of Texas at Arlington, 411 S. Nedderman St, Arlington, TX 76016, USA, Tel +1 817 272 2776, Email
| | - Christy Spivey
- College of Business, University of Texas at Arlington, Arlington, TX, USA
| | - Kathy M Daniel
- College of Nursing, University of Texas at Arlington, Arlington, TX, USA
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