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Haddad-Halloun J, Wexler A, Echar M, Harari-Shaham A, Polager-Modan S, Zaatry R, Maayouf R, Assadi M, Krivoruk O, Peleg A, Sagi-Dain L. The effect of opting-in versus opting-out forming on the rate of reported variants of questionable significance in prenatal microarray. Int J Gynaecol Obstet 2024. [PMID: 39031025 DOI: 10.1002/ijgo.15805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 07/08/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVE To examine the effect of patient-selected opt-in versus opt-out option on the rate of reported variants of uncertain clinical significance (VOUS) and high-frequency low-penetrant (HFLP) findings in prenatal microarray testing. METHODS A standard microarray consent form in Israel includes a requirement to note patient choice to be or not to be informed about the presence of VOUS and HFLP variants. The original form was designed as an opting-out method, in which the women had to actively mark if they did not want to be informed about questionable findings. In the authors' Genetic Institute, the form was changed for an opting-in option in October 2019. In this study we have compared the rates of reported VOUS and HFLP variants between the opt-in and opt-out periods. RESULTS Of the 1014 prenatal CMA tests, 590 (58.2%) were performed in the opt-out period. A significant decrease in the rate of women requesting to be informed of VOUS findings was noted (66.8% in opt-out period vs 34.0% in opt-in period), yielding a relative risk (RR) of 0.46 (95% confidence interval [CI] 0.39-0.53). Rate of women preferring to be informed of HFLP variants decreased from 75.3% to 48.1% (RR 0.52, 95% CI 0.45-0.60). DISCUSSION We present a simple and effective method to decrease the rate of reported findings of questionable significance in the prenatal setting. These results are important not only for microarray results, but also for next-generation sequencing techniques, such as whole exome or genome sequencing.
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Affiliation(s)
| | - Ava Wexler
- The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Moran Echar
- The Human Genetic Institute, Carmel Medical Center, Haifa, Israel
| | | | | | - Rawan Zaatry
- The Human Genetic Institute, Carmel Medical Center, Haifa, Israel
| | - Rasha Maayouf
- The Human Genetic Institute, Carmel Medical Center, Haifa, Israel
| | - Maisa Assadi
- The Human Genetic Institute, Carmel Medical Center, Haifa, Israel
| | - Olga Krivoruk
- The Human Genetic Institute, Carmel Medical Center, Haifa, Israel
| | - Amir Peleg
- The Human Genetic Institute, Carmel Medical Center, Haifa, Israel
| | - Lena Sagi-Dain
- The Human Genetic Institute, Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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2
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Takvorian SU, Gabriel P, Wileyto EP, Blumenthal D, Tejada S, Clifton ABW, Asch DA, Buttenheim AM, Rendle KA, Shelton RC, Chaiyachati KH, Fayanju OM, Ware S, Schuchter LM, Kumar P, Salam T, Lieberman A, Ragusano D, Bauer AM, Scott CA, Shulman LN, Schnoll R, Beidas RS, Bekelman JE, Parikh RB. Clinician- and Patient-Directed Communication Strategies for Patients With Cancer at High Mortality Risk: A Cluster Randomized Trial. JAMA Netw Open 2024; 7:e2418639. [PMID: 38949813 PMCID: PMC11217875 DOI: 10.1001/jamanetworkopen.2024.18639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/23/2024] [Indexed: 07/02/2024] Open
Abstract
Importance Serious illness conversations (SICs) that elicit patients' values, goals, and care preferences reduce anxiety and depression and improve quality of life, but occur infrequently for patients with cancer. Behavioral economic implementation strategies (nudges) directed at clinicians and/or patients may increase SIC completion. Objective To test the independent and combined effects of clinician and patient nudges on SIC completion. Design, Setting, and Participants A 2 × 2 factorial, cluster randomized trial was conducted from September 7, 2021, to March 11, 2022, at oncology clinics across 4 hospitals and 6 community sites within a large academic health system in Pennsylvania and New Jersey among 163 medical and gynecologic oncology clinicians and 4450 patients with cancer at high risk of mortality (≥10% risk of 180-day mortality). Interventions Clinician clusters and patients were independently randomized to receive usual care vs nudges, resulting in 4 arms: (1) active control, operating for 2 years prior to trial start, consisting of clinician text message reminders to complete SICs for patients at high mortality risk; (2) clinician nudge only, consisting of active control plus weekly peer comparisons of clinician-level SIC completion rates; (3) patient nudge only, consisting of active control plus a preclinic electronic communication designed to prime patients for SICs; and (4) combined clinician and patient nudges. Main Outcomes and Measures The primary outcome was a documented SIC in the electronic health record within 6 months of a participant's first clinic visit after randomization. Analysis was performed on an intent-to-treat basis at the patient level. Results The study accrued 4450 patients (median age, 67 years [IQR, 59-75 years]; 2352 women [52.9%]) seen by 163 clinicians, randomized to active control (n = 1004), clinician nudge (n = 1179), patient nudge (n = 997), or combined nudges (n = 1270). Overall patient-level rates of 6-month SIC completion were 11.2% for the active control arm (112 of 1004), 11.5% for the clinician nudge arm (136 of 1179), 11.5% for the patient nudge arm (115 of 997), and 14.1% for the combined nudge arm (179 of 1270). Compared with active control, the combined nudges were associated with an increase in SIC rates (ratio of hazard ratios [rHR], 1.55 [95% CI, 1.00-2.40]; P = .049), whereas the clinician nudge (HR, 0.95 [95% CI, 0.64-1.41; P = .79) and patient nudge (HR, 0.99 [95% CI, 0.73-1.33]; P = .93) were not. Conclusions and Relevance In this cluster randomized trial, nudges combining clinician peer comparisons with patient priming questionnaires were associated with a marginal increase in documented SICs compared with an active control. Combining clinician- and patient-directed nudges may help to promote SICs in routine cancer care. Trial Registration ClinicalTrials.gov Identifier: NCT04867850.
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Affiliation(s)
| | - Peter Gabriel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - E. Paul Wileyto
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel Blumenthal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sharon Tejada
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alicia B. W. Clifton
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Wicked Saints Studios, Medford, Oregon
| | - David A. Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alison M. Buttenheim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- School of Nursing, University of Pennsylvania, Philadelphia
| | | | - Rachel C. Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Krisda H. Chaiyachati
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Verily Life Sciences, San Francisco, California
| | | | - Susan Ware
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lynn M. Schuchter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Pallavi Kumar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Tasnim Salam
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- New Jersey Department of Health Communicable Disease Service, Trenton, New Jersey
| | - Adina Lieberman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel Ragusano
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- School of Medicine, American University of the Caribbean, Cupecoy, Sint Maarten
| | - Anna-Marika Bauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Critical Path Institute, Tucson, Arizona
| | - Callie A. Scott
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Cohere Health, Ann Arbor, Michigan
| | | | - Robert Schnoll
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rinad S. Beidas
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Ravi B. Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Mehta SJ, Rhodes C, Linn KA, Reitz C, McDonald C, Okorie E, Williams K, Resnick D, Arostegui A, McAuliffe T, Wollack C, Snider CK, Peifer MK, Weinstein SP. Behavioral Interventions to Improve Breast Cancer Screening Outreach: Two Randomized Clinical Trials. JAMA Intern Med 2024; 184:761-768. [PMID: 38709509 PMCID: PMC11074930 DOI: 10.1001/jamainternmed.2024.0495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/02/2024] [Indexed: 05/07/2024]
Abstract
Importance Despite public health efforts, breast cancer screening rates remain below national goals. Objective To evaluate whether bulk ordering, text messaging, and clinician endorsement increase breast cancer screening rates. Design, Setting, and Participants Two concurrent, pragmatic, randomized clinical trials, each with a 2-by-2 factorial design, were conducted between October 25, 2021, and April 25, 2022, in 2 primary care regions of an academic health system. The trials included women aged 40 to 74 years with at least 1 primary care visit in the past 2 years who were eligible for breast cancer screening. Interventions Patients in trial A were randomized in a 1:1 ratio to receive a signed bulk order for mammogram or no order; in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Patients in trial B were randomized in a 1:1 ratio to receive a message signed by their primary care clinician (clinician endorsement) or from the organization (standard messaging); in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Main Outcomes and Measures The primary outcome was the proportion of patients who completed a screening mammogram within 3 months. Results Among 24 632 patients included, the mean (SD) age was 60.4 (7.5) years. In trial A, at 3 months, 15.4% (95% CI, 14.6%-16.1%) of patients in the bulk order arm and 12.7% (95% CI, 12.1%-13.4%) in the no order arm completed a mammogram, showing a significant increase (absolute difference, 2.7%; 95% CI, 1.6%-3.6%; P < .001). In the text messaging comparison arms, 15.1% (95% CI, 14.3%-15.8%) of patients receiving a text message completed a mammogram compared with 13.0% (95% CI, 12.4%-13.7%) of those in the no text messaging arm, a significant increase (absolute difference of 2.1%; 95% CI, 1.0%-3.0%; P < .001). In trial B, at 3 months, 12.5% (95% CI, 11.3%-13.7%) of patients in the clinician endorsement arm completed a mammogram compared with 11.4% (95% CI, 10.3%-12.5%) of those in the standard messaging arm, which was not significant (absolute difference, 1.1%; 95% CI, -0.5% to 2.7%; P = .18). In the text messaging comparison arms, 13.2% (95% CI, 12.0%-14.4%) of patients receiving a text message completed a mammogram compared with 10.7% (95% CI, 9.7%-11.8%) of those in the no text messaging arm, a significant increase (absolute difference, 2.5%; 95% CI, 0.8%-4.0%; P = .003). Conclusions and Relevance These findings show that text messaging women after initial breast cancer screening outreach via either electronic portal or mailings, as well as bulk ordering with or without text messaging, can increase mammogram completion rates. Trial Registration ClinicalTrials.gov Identifier: NCT05089903.
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Affiliation(s)
- Shivan J. Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Corinne Rhodes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Kristin A. Linn
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Caitlin McDonald
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Evelyn Okorie
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Keyirah Williams
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - David Resnick
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | | | - Timothy McAuliffe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Colin Wollack
- Penn Medicine, University of Pennsylvania, Philadelphia
| | | | - MaryAnne K. Peifer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine, University of Pennsylvania, Philadelphia
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Rendle KA, Tan ASL, Spring B, Bange EM, Lipitz-Snyderman A, Morris MJ, Makarov DV, Daly R, Garcia SF, Hitsman B, Ogedegbe O, Phillips S, Sherman SE, Stetson PD, Vachani A, Wainwright JV, Zullig LL, Bekelman JE. A Framework for Integrating Telehealth Equitably across the cancer care continuum. J Natl Cancer Inst Monogr 2024; 2024:92-99. [PMID: 38924790 PMCID: PMC11207920 DOI: 10.1093/jncimonographs/lgae021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/23/2024] [Accepted: 04/15/2024] [Indexed: 06/28/2024] Open
Abstract
The COVID-19 pandemic placed a spotlight on the potential to dramatically increase the use of telehealth across the cancer care continuum, but whether and how telehealth can be implemented in practice in ways that reduce, rather than exacerbate, inequities are largely unknown. To help fill this critical gap in research and practice, we developed the Framework for Integrating Telehealth Equitably (FITE), a process and evaluation model designed to help guide equitable integration of telehealth into practice. In this manuscript, we present FITE and showcase how investigators across the National Cancer Institute's Telehealth Research Centers of Excellence are applying the framework in different ways to advance digital and health equity. By highlighting multilevel determinants of digital equity that span further than access alone, FITE highlights the complex and differential ways structural determinants restrict or enable digital equity at the individual and community level. As such, achieving digital equity will require strategies designed to not only support individual behavior but also change the broader context to ensure all patients and communities have the choice, opportunity, and resources to use telehealth across the cancer care continuum.
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Affiliation(s)
- Katharine A Rendle
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, PA, USA
| | - Andy S L Tan
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, PA, USA
- Annenberg School for Communications, University of Pennsylvania, Philadelphia, PA, USA
| | - Bonnie Spring
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Erin M Bange
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Danil V Makarov
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
- Department of Urology, New York University Grossman School of Medicine, New York, New York
- Department of Medicine, VA New York Harbor Healthcare System, New York, NY, USA
| | - Robert Daly
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sofia F Garcia
- Department of Medical Social Sciences and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brian Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Olugbenga Ogedegbe
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Siobhan Phillips
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Scott E Sherman
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
- Department of Medicine, VA New York Harbor Healthcare System, New York, NY, USA
| | | | - Anil Vachani
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Jocelyn V Wainwright
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, PA, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Justin E Bekelman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, PA, USA
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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5
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Soames J, Pettigrew LM. Electronic health record-based behaviour change interventions aimed at general practitioners in the UK: a mixed methods systematic review using behaviour change theory. BMJ Open 2024; 14:e080546. [PMID: 38816046 PMCID: PMC11141199 DOI: 10.1136/bmjopen-2023-080546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/24/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES Electronic health record (EHR) systems are used extensively in healthcare; their design can influence clinicians' behaviour. We conducted a systematic review of EHR-based interventions aimed at changing the clinical practice of general practitioners in the UK, assessed their effectiveness and applied behaviour change theory to identify lessons for other settings. DESIGN Mixed methods systematic review. DATA SOURCES MEDLINE, EMBASE, CENTRAL and APA PsycINFO were searched up to March 2023. ELIGIBILITY CRITERIA Quantitative and qualitative findings from randomised controlled trials (RCTs) controlled before-and-after studies and interrupted time series of EHR-based interventions in UK general practice were included. DATA EXTRACTION AND SYNTHESIS Quantitative synthesis was based on Cochrane's Synthesis without Meta-analysis. Interventions were categorised using the Behaviour Change Wheel and MINDSPACE frameworks and effectiveness determined by vote-counting using direction of effect. Inductive thematic synthesis was used for qualitative studies. RESULTS Database searching identified 3824 unique articles; 10 were included (from 2002 to 2021), comprising eight RCTs and two associated qualitative studies. Four of seven quantitative studies showed a positive effect on clinician behaviour and three on patient-level outcomes. Behaviour change techniques that may trigger emotions and required less cognitive engagement appeared to have positive effects. Qualitative findings indicated that interventions reassured clinicians of their decisions but were sometimes ignored. CONCLUSION Despite widespread use, there is little high quality, up-to-date experimental evidence evaluating the effectiveness of EHR-based interventions in UK general practice. The evidence suggested EHR-based interventions may be effective at changing behaviour. Persistent, simple action-oriented prompts appeared more effective than complex interventions requiring greater cognitive engagement. However, studies lacked detail in intervention design and theory behind design choices. Future research should seek to optimise EHR-based behaviour change intervention design and delineate limitations, providing theory-based justification for interventions. This will be of increasing importance with the growing use of EHRs to influence clinicians' decisions. PROSPERO REGISTRATION NUMBER CRD42022341009.
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Affiliation(s)
- Jamie Soames
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Luisa M Pettigrew
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Samal L, Kilgallon JL, Lipsitz S, Baer HJ, McCoy A, Gannon M, Noonan S, Dunk R, Chen SW, Chay WI, Fay R, Garabedian PM, Wu E, Wien M, Blecker S, Salmasian H, Bonventre JV, McMahon GM, Bates DW, Waikar SS, Linder JA, Wright A, Dykes P. Clinical Decision Support for Hypertension Management in Chronic Kidney Disease: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:484-492. [PMID: 38466302 PMCID: PMC10928544 DOI: 10.1001/jamainternmed.2023.8315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/11/2023] [Indexed: 03/12/2024]
Abstract
Importance Chronic kidney disease (CKD) affects 37 million adults in the United States, and for patients with CKD, hypertension is a key risk factor for adverse outcomes, such as kidney failure, cardiovascular events, and death. Objective To evaluate a computerized clinical decision support (CDS) system for the management of uncontrolled hypertension in patients with CKD. Design, Setting, and Participants This multiclinic, randomized clinical trial randomized primary care practitioners (PCPs) at a primary care network, including 15 hospital-based, ambulatory, and community health center-based clinics, through a stratified, matched-pair randomization approach February 2021 to February 2022. All adult patients with a visit to a PCP in the last 2 years were eligible and those with evidence of CKD and hypertension were included. Intervention The intervention consisted of a CDS system based on behavioral economic principles and human-centered design methods that delivered tailored, evidence-based recommendations, including initiation or titration of renin-angiotensin-aldosterone system inhibitors. The patients in the control group received usual care from PCPs with the CDS system operating in silent mode. Main Outcomes and Measures The primary outcome was the change in mean systolic blood pressure (SBP) between baseline and 180 days compared between groups. The primary analysis was a repeated measures linear mixed model, using SBP at baseline, 90 days, and 180 days in an intention-to-treat repeated measures model to account for missing data. Secondary outcomes included blood pressure (BP) control and outcomes such as percentage of patients who received an action that aligned with the CDS recommendations. Results The study included 174 PCPs and 2026 patients (mean [SD] age, 75.3 [0.3] years; 1223 [60.4%] female; mean [SD] SBP at baseline, 154.0 [14.3] mm Hg), with 87 PCPs and 1029 patients randomized to the intervention and 87 PCPs and 997 patients randomized to usual care. Overall, 1714 patients (84.6%) were treated for hypertension at baseline. There were 1623 patients (80.1%) with an SBP measurement at 180 days. From the linear mixed model, there was a statistically significant difference in mean SBP change in the intervention group compared with the usual care group (change, -14.6 [95% CI, -13.1 to -16.0] mm Hg vs -11.7 [-10.2 to -13.1] mm Hg; P = .005). There was no difference in the percentage of patients who achieved BP control in the intervention group compared with the control group (50.4% [95% CI, 46.5% to 54.3%] vs 47.1% [95% CI, 43.3% to 51.0%]). More patients received an action aligned with the CDS recommendations in the intervention group than in the usual care group (49.9% [95% CI, 45.1% to 54.8%] vs 34.6% [95% CI, 29.8% to 39.4%]; P < .001). Conclusions and Relevance These findings suggest that implementing this computerized CDS system could lead to improved management of uncontrolled hypertension and potentially improved clinical outcomes at the population level for patients with CKD. Trial Registration ClinicalTrials.gov Identifier: NCT03679247.
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Affiliation(s)
- Lipika Samal
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - John L. Kilgallon
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Stuart Lipsitz
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Heather J. Baer
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Allison McCoy
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee
| | - Michael Gannon
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Eastern Virginia Medical School, Norfolk
| | - Sarah Noonan
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- USC School of Medicine Greenville, Greenville, South Carolina
| | - Ryan Dunk
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sarah W. Chen
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Weng Ian Chay
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Richard Fay
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Edward Wu
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Alabama College of Osteopathic Medicine, Dothan
| | - Matthew Wien
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Saul Blecker
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Joseph V. Bonventre
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Gearoid M. McMahon
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - David W. Bates
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sushrut S. Waikar
- Section of Nephrology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Jeffrey A. Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee
| | - Patricia Dykes
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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7
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O'Leary ST, Opel DJ, Cataldi JR, Hackell JM. Strategies for Improving Vaccine Communication and Uptake. Pediatrics 2024; 153:e2023065483. [PMID: 38404211 DOI: 10.1542/peds.2023-065483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/27/2024] Open
Abstract
Vaccines have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about the scope and impact of the problem, the facts surrounding common vaccination concerns, and the latest evidence regarding effective communication techniques for the vaccine conversation. After reading this clinical report, readers can expect to: Understand concepts and underlying determinants of vaccine uptake and vaccine hesitancy.Understand the relationship between vaccine hesitancy and costs of preventable medical care.Recognize and address specific concerns (eg, vaccine safety) with caregivers when hesitancy is present.
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Affiliation(s)
- Sean T O'Leary
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, Colorado
| | - Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Jessica R Cataldi
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, Colorado
| | - Jesse M Hackell
- Department of Pediatrics, New York Medical College, Valhalla, New York
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Courtright KR, Madden V, Bayes B, Chowdhury M, Whitman C, Small DS, Harhay MO, Parra S, Cooney-Zingman E, Ersek M, Escobar GJ, Hill SH, Halpern SD. Default Palliative Care Consultation for Seriously Ill Hospitalized Patients: A Pragmatic Cluster Randomized Trial. JAMA 2024; 331:224-232. [PMID: 38227032 PMCID: PMC10792472 DOI: 10.1001/jama.2023.25092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/14/2023] [Indexed: 01/17/2024]
Abstract
Importance Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking. Objective To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and improved outcomes. Design, Setting, and Participants A pragmatic, stepped-wedge, cluster randomized trial was conducted among patients 65 years or older with advanced chronic obstructive pulmonary disease, dementia, or kidney failure admitted from March 21, 2016, through November 14, 2018, to 11 US hospitals. Outcome data collection ended on January 31, 2019. Intervention Ordering palliative care consultation by default for eligible patients, while allowing clinicians to opt-out, was compared with usual care, in which clinicians could choose to order palliative care. Main Outcomes and Measures The primary outcome was hospital length of stay, with deaths coded as the longest length of stay, and secondary end points included palliative care consult rate, discharge to hospice, do-not-resuscitate orders, and in-hospital mortality. Results Of 34 239 patients enrolled, 24 065 had lengths of stay of at least 72 hours and were included in the primary analytic sample (10 313 in the default order group and 13 752 in the usual care group; 13 338 [55.4%] women; mean age, 77.9 years). A higher percentage of patients in the default order group received palliative care consultation than in the standard care group (43.9% vs 16.6%; adjusted odds ratio [aOR], 5.17 [95% CI, 4.59-5.81]) and received consultation earlier (mean [SD] of 3.4 [2.6] days after admission vs 4.6 [4.8] days; P < .001). Length of stay did not differ between the default order and usual care groups (percent difference in median length of stay, -0.53% [95% CI, -3.51% to 2.53%]). Patients in the default order group had higher rates of do-not-resuscitate orders at discharge (aOR, 1.40 [95% CI, 1.21-1.63]) and discharge to hospice (aOR, 1.30 [95% CI, 1.07-1.57]) than the usual care group, and similar in-hospital mortality (4.7% vs 4.2%; aOR, 0.86 [95% CI, 0.68-1.08]). Conclusions and Relevance Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes. Trial Registration ClinicalTrials.gov Identifier: NCT02505035.
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Affiliation(s)
- Katherine R. Courtright
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Vanessa Madden
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
| | - Casey Whitman
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
| | - Dylan S. Small
- Department of Statistics, Wharton School, University of Pennsylvania, Philadelphia
| | - Michael O. Harhay
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | | | - Elizabeth Cooney-Zingman
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Mary Ersek
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia
| | | | | | - Scott D. Halpern
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
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Mehta SJ, McDonald C, Reitz C, Kastuar S, Snider CK, Okorie E, McNelis K, Shaikh H, Cook TS, Goldberg DS, Rothstein K. A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance. Hepatol Commun 2024; 8:e0349. [PMID: 38099859 PMCID: PMC10727671 DOI: 10.1097/hc9.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Surveillance rates for HCC remain limited in patients with cirrhosis. We evaluated whether opt-out mailed outreach increased uptake with or without a $20 unconditional incentive. METHODS This was a pragmatic randomized controlled trial in an urban academic health system including adult patients with cirrhosis or advanced fibrosis, at least 1 visit to a specialty practice in the past 2 years and no surveillance in the last 7 months. Patients were randomized in a 1:2:2 ratio to (1) usual care, (2) a mailed letter with a signed order for an ultrasound, or (3) a mailed letter with an order and a $20 unconditional incentive. The main outcome was the proportion with completion of ultrasound within 6 months. RESULTS Among the 562 patients included, the mean age was 62.1 (SD 11.1); 56.8% were male, 51.1% had Medicare, and 40.6% were Black. At 6 months, 27.6% (95% CI: 19.5-35.7) completed ultrasound in the Usual care arm, 54.5% (95% CI: 47.9-61.0) in the Letter + Order arm, and 54.1% (95% CI: 47.5-60.6) in the Letter + Order + Incentive arm. There was a significant increase in the Letter + Order arm compared to Usual care (absolute difference of 26.9%; 95% CI: 16.5-37.3; p<0.001), but no significant increase in the Letter + Order + Incentive arm compared to Letter + Order (absolute difference of -0.4; 95% CI: -9.7 to 8.8; p=0.93). CONCLUSIONS There was an increase in HCC surveillance from mailed outreach with opt-out framing and a signed order slip, but no increase in response to the financial incentive.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Shivani Kastuar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Evelyn Okorie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Kiernan McNelis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Hamzah Shaikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Tessa S. Cook
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - David S. Goldberg
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Kenneth Rothstein
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Plaisance A, Mallmes J, Kamateros A, Heyland DK. Evaluation of a French adaptation of a community-based advance serious illness planning decision aid. PEC INNOVATION 2023; 3:100182. [PMID: 38213761 PMCID: PMC10782113 DOI: 10.1016/j.pecinn.2023.100182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/17/2023] [Accepted: 06/17/2023] [Indexed: 01/13/2024]
Abstract
Objective The Plan Well Guide™ (PWG) is a decision aid that empowers lay persons to better understand different types of care and prepares them, and their substitute decision-makers, to express both their authentic values and informed treatment preferences in anticipation of serious illness. We aimed to determine the acceptability of the newly translated French PWG and to evaluate decisional readiness and decisional conflict following its use by lay people. Methods This is an acceptability and exploratory outcomes evaluation.Participants were requested to read and complete the French PWG and to engage in an online interview. We used the Acceptability Scale to determine the acceptability and the Preparation for Decision-making Scale and decisional conflict Scale to evaluate decisional readiness. Results Forty-two (42) people participated. The average score on the Acceptability Scale was 18.1 (scale range: 4-20 [high-better]) and 26.6 on the Preparation for Decision-Making Scale (scale range: 6-30 [high-better]). A significant number of respondents reported needing more support to help them make better decisions. Conclusion The French PWG has been deemed acceptable and relevant for lay people not currently facing clinical decisions. Innovation The Plan Well Guide is innovative as it is the first decision aid empowering lay people for advance serious illness planning.
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11
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McCarthy AM, Fernandez Perez C, Beidas RS, Bekelman JE, Blumenthal D, Mack E, Bauer AM, Ehsan S, Conant EF, Wheeler BC, Guerra CE, Nunes LW, Gabriel P, Doucette A, Wileyto EP, Buttenheim AM, Asch DA, Rendle KA, Shelton RC, Fayanju OM, Ware S, Plag M, Hyland S, Gionta T, Shulman LN, Schnoll R. Protocol for a pragmatic stepped wedge cluster randomized clinical trial testing behavioral economic implementation strategies to increase supplemental breast MRI screening among patients with extremely dense breasts. Implement Sci 2023; 18:65. [PMID: 38001506 PMCID: PMC10668465 DOI: 10.1186/s13012-023-01323-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Increased breast density augments breast cancer risk and reduces mammography sensitivity. Supplemental breast MRI screening can significantly increase cancer detection among women with dense breasts. However, few women undergo this exam, and screening is consistently lower among racially minoritized populations. Implementation strategies informed by behavioral economics ("nudges") can promote evidence-based practices by improving clinician decision-making under conditions of uncertainty. Nudges directed toward clinicians and patients may facilitate the implementation of supplemental breast MRI. METHODS Approximately 1600 patients identified as having extremely dense breasts after non-actionable mammograms, along with about 1100 clinicians involved with their care at 32 primary care or OB/GYN clinics across a racially diverse academically based health system, will be enrolled. A 2 × 2 randomized pragmatic trial will test nudges to patients, clinicians, both, or neither to promote supplemental breast MRI screening. Before implementation, rapid cycle approaches informed by clinician and patient experiences and behavioral economics and health equity frameworks guided nudge design. Clinicians will be clustered into clinic groups based on existing administrative departments and care patterns, and these clinic groups will be randomized to have the nudge activated at different times per a stepped wedge design. Clinicians will receive nudges integrated into the routine mammographic report or sent through electronic health record (EHR) in-basket messaging once their clinic group (i.e., wedge) is randomized to receive the intervention. Independently, patients will be randomized to receive text message nudges or not. The primary outcome will be defined as ordering or scheduling supplemental breast MRI. Secondary outcomes include MRI completion, cancer detection rates, and false-positive rates. Patient sociodemographic information and clinic-level variables will be examined as moderators of nudge effectiveness. Qualitative interviews conducted at the trial's conclusion will examine barriers and facilitators to implementation. DISCUSSION This study will add to the growing literature on the effectiveness of behavioral economics-informed implementation strategies to promote evidence-based interventions. The design will facilitate testing the relative effects of nudges to patients and clinicians and the effects of moderators of nudge effectiveness, including key indicators of health disparities. The results may inform the introduction of low-cost, scalable implementation strategies to promote early breast cancer detection. TRIAL REGISTRATION ClinicalTrials.gov NCT05787249. Registered on March 28, 2023.
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Affiliation(s)
- Anne Marie McCarthy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | | | - Rinad S Beidas
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Justin E Bekelman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Daniel Blumenthal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Mack
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna-Marika Bauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Ehsan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily F Conant
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Carmen E Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Linda W Nunes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter Gabriel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Abigail Doucette
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E Paul Wileyto
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Alison M Buttenheim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Rachel C Shelton
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Oluwadamilola M Fayanju
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Sue Ware
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Martina Plag
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Hyland
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tracy Gionta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Robert Schnoll
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
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12
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Symecko H, Schnoll R, Beidas RS, Bekelman JE, Blumenthal D, Bauer AM, Gabriel P, Boisseau L, Doucette A, Powers J, Cappadocia J, McKenna DB, Richardville R, Cuff L, Offer R, Clement EG, Buttenheim AM, Asch DA, Rendle KA, Shelton RC, Fayanju OM, Wileyto EP, Plag M, Ware S, Shulman LN, Nathanson KL, Domchek SM. Protocol to evaluate sequential electronic health record-based strategies to increase genetic testing for breast and ovarian cancer risk across diverse patient populations in gynecology practices. Implement Sci 2023; 18:57. [PMID: 37932730 PMCID: PMC10629034 DOI: 10.1186/s13012-023-01308-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/29/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Germline genetic testing is recommended by the National Comprehensive Cancer Network (NCCN) for individuals including, but not limited to, those with a personal history of ovarian cancer, young-onset (< 50 years) breast cancer, and a family history of ovarian cancer or male breast cancer. Genetic testing is underused overall, and rates are consistently lower among Black and Hispanic populations. Behavioral economics-informed implementation strategies, or nudges, directed towards patients and clinicians may increase the use of this evidence-based clinical practice. METHODS Patients meeting eligibility for germline genetic testing for breast and ovarian cancer will be identified using electronic phenotyping algorithms. A pragmatic cohort study will test three sequential strategies to promote genetic testing, two directed at patients and one directed at clinicians, deployed in the electronic health record (EHR) for patients in OB-GYN clinics across a diverse academic medical center. We will use rapid cycle approaches informed by relevant clinician and patient experiences, health equity, and behavioral economics to optimize and de-risk our strategies and methods before trial initiation. Step 1 will send patients messages through the health system patient portal. For non-responders, step 2 will reach out to patients via text message. For non-responders, Step 3 will contact patients' clinicians using a novel "pend and send" tool in the EHR. The primary implementation outcome is engagement with germline genetic testing for breast and ovarian cancer predisposition, defined as a scheduled genetic counseling appointment. Patient data collected through the EHR (e.g., race/ethnicity, geocoded address) will be examined as moderators of the impact of the strategies. DISCUSSION This study will be one of the first to sequentially examine the effects of patient- and clinician-directed strategies informed by behavioral economics on engagement with breast and ovarian cancer genetic testing. The pragmatic and sequential design will facilitate a large and diverse patient sample, allow for the assessment of incremental gains from different implementation strategies, and permit the assessment of moderators of strategy effectiveness. The findings may help determine the impact of low-cost, highly transportable implementation strategies that can be integrated into healthcare systems to improve the use of genomic medicine. TRIAL REGISTRATION ClinicalTrials.gov. NCT05721326. Registered February 10, 2023. https://www. CLINICALTRIALS gov/study/NCT05721326.
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Affiliation(s)
- Heather Symecko
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Basser Center for BRCA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Robert Schnoll
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Rinad S Beidas
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Justin E Bekelman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Daniel Blumenthal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna-Marika Bauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter Gabriel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Leland Boisseau
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Abigail Doucette
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Jacquelyn Powers
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Basser Center for BRCA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacqueline Cappadocia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Basser Center for BRCA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Danielle B McKenna
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Basser Center for BRCA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Richardville
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Basser Center for BRCA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren Cuff
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Basser Center for BRCA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Offer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth G Clement
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alison M Buttenheim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Rachel C Shelton
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Oluwadamilola M Fayanju
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - E Paul Wileyto
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Martina Plag
- Center for Healthcare Transformation and Innovation, Penn Medicine, Philadelphia, PA, USA
| | - Sue Ware
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Katherine L Nathanson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Basser Center for BRCA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Susan M Domchek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Basser Center for BRCA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA.
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13
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Jenssen BP, Schnoll R, Beidas RS, Bekelman J, Bauer AM, Evers-Casey S, Fisher T, Scott C, Nicoloso J, Gabriel P, Asch DA, Buttenheim AM, Chen J, Melo J, Grant D, Horst M, Oyer R, Shulman LN, Clifton AB, Lieberman A, Salam T, Rendle KA, Chaiyachati KH, Shelton RC, Fayanju O, Wileyto EP, Ware S, Blumenthal D, Ragusano D, Leone FT. Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke. J Clin Oncol 2023; 41:4511-4521. [PMID: 37467454 PMCID: PMC10552951 DOI: 10.1200/jco.23.00355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/25/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023] Open
Abstract
PURPOSE Few cancer centers systematically engage patients with evidence-based tobacco treatment despite its positive effect on quality of life and survival. Implementation strategies directed at patients, clinicians, or both may increase tobacco use treatment (TUT) within oncology. METHODS We conducted a four-arm cluster-randomized pragmatic trial across 11 clinical sites comparing the effect of strategies informed by behavioral economics on TUT engagement during oncology encounters with cancer patients. We delivered electronic health record (EHR)-based nudges promoting TUT across four nudge conditions: patient only, clinician only, patient and clinician, or usual care. Nudges were designed to counteract cognitive biases that reduce TUT engagement. The primary outcome was TUT penetration, defined as the proportion of patients with documented TUT referral or a medication prescription in the EHR. Generalized estimating equations were used to estimate the parameters of a linear model. RESULTS From June 2021 to July 2022, we randomly assigned 246 clinicians in 95 clusters, and collected TUT penetration data from their encounters with 2,146 eligible patients who smoke receiving oncologic care. Intent-to-treat (ITT) analysis showed that the clinician nudge led to a significant increase in TUT penetration versus usual care (35.6% v 13.5%; OR = 3.64; 95% CI, 2.52 to 5.24; P < .0001). Completer-only analysis (N = 1,795) showed similar impact (37.7% clinician nudge v 13.5% usual care; OR = 3.77; 95% CI, 2.73 to 5.19; P < .0001). Clinician type affected TUT penetration, with physicians less likely to provide TUT than advanced practice providers (ITT OR = 0.67; 95% CI, 0.51 to 0.88; P = .004). CONCLUSION EHR nudges, informed by behavioral economics and aimed at oncology clinicians, appear to substantially increase TUT penetration. Adding patient nudges to the implementation strategy did not affect TUT penetration rates.
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Affiliation(s)
- Brian P. Jenssen
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rinad S. Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Justin Bekelman
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Anna-Marika Bauer
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah Evers-Casey
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tierney Fisher
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Callie Scott
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jody Nicoloso
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Peter Gabriel
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David A. Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alison M. Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Jessica Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Julissa Melo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dwayne Grant
- Penn Medicine Lancaster General Health, Lancaster, PA
| | - Michael Horst
- Penn Medicine Lancaster General Health, Lancaster, PA
| | - Randall Oyer
- Penn Medicine Lancaster General Health, Lancaster, PA
| | - Lawrence N. Shulman
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alicia B.W. Clifton
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adina Lieberman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tasnim Salam
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Krisda H. Chaiyachati
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Verily Life Sciences, San Francisco, CA
| | - Rachel C. Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | - Oluwadamilola Fayanju
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - E. Paul Wileyto
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sue Ware
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel Blumenthal
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel Ragusano
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Frank T. Leone
- Pulmonary, Allergy, & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Sherman Z, Wahid N, Wagner M, Soltani A, Rosenblatt R, Fortune B, Lucero C, Schoenfeld E, Brown R, Jesudian A. Integration of Cirrhosis Best Practices Into Electronic Medical Record Documentation Associated With Reduction in 30-Day Mortality Following Hospitalization. J Clin Gastroenterol 2023; 57:951-955. [PMID: 36730665 DOI: 10.1097/mcg.0000000000001787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25% to 30% of hospitalized cirrhotics are readmitted within 30 days. Rehospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well-documented quality gap between evidence-based guidelines for cirrhosis management and real-world adherence to these recommendations. METHODS We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to 4 internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best-practice measures for cirrhotics was developed. Inpatient providers on 2 teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin, and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining 2 teams continued the standard of care for cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best-practice guidelines. RESULTS Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 vs. 21.1, P =0.56). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% vs. 24%, P =0.61). However, 30-day mortality was significantly lower in the interventional group (8.4% vs. 28%, P =0.01). There was no difference between the 2 groups in in-hospital mortality (4.8% vs. 0%, P =0.27), 90-day mortality (15.7% vs. 28.0%, P =0.17) or length of stay (10.2 vs. 12.6 d, P =0.34). Adherence to best-practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% vs. 80%, P =0.01). CONCLUSION Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that the integration of best-practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.
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Affiliation(s)
- Zachary Sherman
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital/Weill Cornell Medical College
| | - Nabeel Wahid
- Department of Medicine, Memorial Sloan Kettering Cancer Center
| | - Michael Wagner
- Department of Medicine, Memorial Sloan Kettering Cancer Center
| | - Amin Soltani
- Division of Gastroenterology, Massachusetts General Hospital
| | - Russell Rosenblatt
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Brett Fortune
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Catherine Lucero
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Emily Schoenfeld
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Robert Brown
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Arun Jesudian
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
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15
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Crowley AP, Sun C, Yan XS, Navathe A, Liao JM, Patel MS, Pagnotti D, Shen Z, Delgado MK. Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions. Acad Emerg Med 2023; 30:809-818. [PMID: 36876410 DOI: 10.1111/acem.14717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity. METHODS The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback. RESULTS Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity. CONCLUSIONS Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.
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Affiliation(s)
- Aidan P Crowley
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Amol Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - David Pagnotti
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zijun Shen
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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16
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Raban MZ, Gates PJ, Gamboa S, Gonzalez G, Westbrook JI. Effectiveness of non-interruptive nudge interventions in electronic health records to improve the delivery of care in hospitals: a systematic review. J Am Med Inform Assoc 2023:7163187. [PMID: 37187160 DOI: 10.1093/jamia/ocad083] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/31/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES To describe the application of nudges within electronic health records (EHRs) and their effects on inpatient care delivery, and identify design features that support effective decision-making without the use of interruptive alerts. MATERIALS AND METHODS We searched Medline, Embase, and PsychInfo (in January 2022) for randomized controlled trials, interrupted time-series and before-after studies reporting effects of nudge interventions embedded in hospital EHRs to improve care. Nudge interventions were identified at full-text review, using a pre-existing classification. Interventions using interruptive alerts were excluded. Risk of bias was assessed using the ROBINS-I tool (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies or the Cochrane Effective Practice and Organization of Care Group methodology for randomized trials. Study results were summarized narratively. RESULTS We included 18 studies evaluating 24 EHR nudges. An improvement in care delivery was reported for 79.2% (n = 19; 95% CI, 59.5-90.8) of nudges. Nudges applied were from 5 of 9 possible nudge categories: change choice defaults (n = 9), make information visible (n = 6), change range or composition of options (n = 5), provide reminders (n = 2), and change option-related effort (n = 2). Only one study had a low risk of bias. Nudges targeted ordering of medications, laboratory tests, imaging, and appropriateness of care. Few studies evaluated long-term effects. DISCUSSION Nudges in EHRs can improve care delivery. Future work could explore a wider range of nudges and evaluate long-term effects. CONCLUSION Nudges can be implemented in EHRs to improve care delivery within current system capabilities; however, as with all digital interventions, careful consideration of the sociotechnical system is crucial to enhance their effectiveness.
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Affiliation(s)
- Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Peter J Gates
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Sarah Gamboa
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Gabriela Gonzalez
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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17
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Opel DJ. Clinician Communication to Address Vaccine Hesitancy. Pediatr Clin North Am 2023; 70:309-319. [PMID: 36841598 DOI: 10.1016/j.pcl.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
There are several factors that influence childhood vaccine uptake. Pediatric clinicians play a particularly influential role in parent vaccine decision-making. It is critical therefore that pediatric clinicians have a "communication toolbox"--a set of effective, evidence-based communication strategies to facilitate uptake of childhood vaccines--that they can use in conversations with parents about vaccines. In this article, recent advances in our understanding of what constitutes effective clinician vaccine communication with parents are discussed.
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Affiliation(s)
- Douglas J Opel
- Department of Pediatrics, University of Washington School of Medicine, Center for Clinical and Translational Research, Seattle Children's Research Institute, M/S: JMB-6, 1900 Ninth Avenue, Seattle, WA 98101, USA.
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18
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Manz CR, Zhang Y, Chen K, Long Q, Small DS, Evans CN, Chivers C, Regli SH, Hanson CW, Bekelman JE, Braun J, Rareshide CAL, O'Connor N, Kumar P, Schuchter LM, Shulman LN, Patel MS, Parikh RB. Long-term Effect of Machine Learning-Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncol 2023; 9:414-418. [PMID: 36633868 PMCID: PMC9857721 DOI: 10.1001/jamaoncol.2022.6303] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Serious illness conversations (SICs) between oncology clinicians and patients are associated with improved quality of life and may reduce aggressive end-of-life care. However, most patients with cancer die without a documented SIC. Objective To test the impact of behavioral nudges to clinicians to prompt SICs on the SIC rate and end-of-life outcomes among patients at high risk of death within 180 days (high-risk patients) as identified by a machine learning algorithm. Design, Setting, and Participants This prespecified 40-week analysis of a stepped-wedge randomized clinical trial conducted between June 17, 2019, and April 20, 2020 (including 16 weeks of intervention rollout and 24 weeks of follow-up), included 20 506 patients with cancer representing 41 021 encounters at 9 tertiary or community-based medical oncology clinics in a large academic health system. The current analyses were conducted from June 1, 2021, to May 31, 2022. Intervention High-risk patients were identified using a validated electronic health record machine learning algorithm to predict 6-month mortality. The intervention consisted of (1) weekly emails to clinicians comparing their SIC rates for all patients against peers' rates, (2) weekly lists of high-risk patients, and (3) opt-out text messages to prompt SICs before encounters with high-risk patients. Main Outcomes and Measures The primary outcome was SIC rates for all and high-risk patient encounters; secondary end-of-life outcomes among decedents included inpatient death, hospice enrollment and length of stay, and intensive care unit admission and systemic therapy close to death. Intention-to-treat analyses were adjusted for clinic and wedge fixed effects and clustered at the oncologist level. Results The study included 20 506 patients (mean [SD] age, 60.0 [14.0] years) and 41 021 patient encounters: 22 259 (54%) encounters with female patients, 28 907 (70.5%) with non-Hispanic White patients, and 5520 (13.5%) with high-risk patients; 1417 patients (6.9%) died by the end of follow-up. There were no meaningful differences in demographic characteristics in the control and intervention periods. Among high-risk patient encounters, the unadjusted SIC rates were 3.4% (59 of 1754 encounters) in the control period and 13.5% (510 of 3765 encounters) in the intervention period. In adjusted analyses, the intervention was associated with increased SICs for all patients (adjusted odds ratio, 2.09 [95% CI, 1.53-2.87]; P < .001) and decreased end-of-life systemic therapy (7.5% [72 of 957 patients] vs 10.4% [24 of 231 patients]; adjusted odds ratio, 0.25 [95% CI, 0.11-0.57]; P = .001) relative to controls, but there was no effect on hospice enrollment or length of stay, inpatient death, or end-of-life ICU use. Conclusions and Relevance In this randomized clinical trial, a machine learning-based behavioral intervention and behavioral nudges to clinicans led to an increase in SICs and reduction in end-of-life systemic therapy but no changes in other end-of-life outcomes among outpatients with cancer. These results suggest that machine learning and behavioral nudges can lead to long-lasting improvements in cancer care delivery. Trial Registration ClinicalTrials.gov Identifier: NCT03984773.
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Affiliation(s)
- Christopher R Manz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Yichen Zhang
- Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kan Chen
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Qi Long
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Dylan S Small
- Wharton School of the University of Pennsylvania, Philadelphia
| | - Chalanda N Evans
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | | | - Justin E Bekelman
- Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | | | - Charles A L Rareshide
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nina O'Connor
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Pallavi Kumar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Lynn M Schuchter
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Lawrence N Shulman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | | | - Ravi B Parikh
- Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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19
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Real-World Observational Evaluation of Common Interventions to Reduce Emergency Department Prescribing of Opioid Medications. Jt Comm J Qual Patient Saf 2023; 49:239-246. [PMID: 36914528 DOI: 10.1016/j.jcjq.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real-world opioid stewardship policies are concurrent and overlapping, the authors examined the effect of such policies on emergency department (ED) opioid prescriptions. METHODS The researchers performed observational analysis of all ED visits discharged between December 17, 2016, and December 31, 2019, across seven EDs of a hospital system. Four interventions were examined in chronological order, with each successive intervention added on top of all previous interventions: 12-pill prescription default, EPCS, electronic health record (EHR) pop-up alert, and 8-pill prescription default. The primary outcome was opioid prescribing, which was described as number of opioid prescriptions per 100 discharged ED visits and modeled as a binary outcome for each visit. Secondary outcomes included prescription morphine milligram equivalents (MME) and non-opioid analgesia prescriptions. RESULTS A total of 775,692 ED visits were included in the study. Compared to the preintervention period, cumulative reductions in opioid prescribing were seen with incremental interventions, including after adding a 12-pill default (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.82-0.94), after adding EPCS (OR 0.7, 95% CI 0.63-0.77), after adding pop-up alerts (OR 0.67, 95% CI 0.63-0.71), and after adding an 8-pill default (OR 0.61, 95% CI 0.58-0.65). CONCLUSION EHR-implemented solutions such as EPCS, pop-up alerts, and pill defaults had varying but significant effects on reducing ED opioid prescribing. Policy makers and quality improvement leaders might achieve sustainable improvements in opioid stewardship while balancing clinician alert fatigue through policy efforts promoting implementation of EPCS and default dispense quantities.
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20
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Use of clinical pathways integrated into the electronic health record to address the coronavirus disease 2019 (COVID-19) pandemic. Infect Control Hosp Epidemiol 2023; 44:260-267. [PMID: 35314010 PMCID: PMC9043631 DOI: 10.1017/ice.2022.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has required healthcare systems to meet new demands for rapid information dissemination, resource allocation, and data reporting. To help address these challenges, our institution leveraged electronic health record (EHR)-integrated clinical pathways (E-ICPs), which are easily understood care algorithms accessible at the point of care. OBJECTIVE To describe our institution's creation of E-ICPs to address the COVID-19 pandemic, and to assess the use and impact of these tools. SETTING Urban academic medical center with adult and pediatric hospitals, emergency departments, and ambulatory practices. METHODS Using the E-ICP processes and infrastructure established at our institution as a foundation, we developed a suite of COVID-19-specific E-ICPs along with a process for frequent reassessment and updating. We examined the development and use of our COVID-19-specific pathways for a 6-month period (March 1-September 1, 2020), and we have described their impact using case studies. RESULTS In total, 45 COVID-19-specific pathways were developed, pertaining to triage, diagnosis, and management of COVID-19 in diverse patient settings. Orders available in E-ICPs included those for isolation precautions, testing, treatments, admissions, and transfers. Pathways were accessed 86,400 times, with 99,081 individual orders were placed. Case studies demonstrate the impact of COVID-19 E-ICPs on stewardship of resources, testing optimization, and data reporting. CONCLUSIONS E-ICPs provide a flexible and unified mechanism to meet the evolving demands of the COVID-19 pandemic, and they continue to be a critical tool leveraged by clinicians and hospital administrators alike for the management of COVID-19. Lessons learned may be generalizable to other urgent and nonurgent clinical conditions.
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21
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Sangal RB, Venkatesh AK, Cahill J, Pettker CM, Peaper DR. Choice Architecture to Assist Clinicians with Appropriate COVID-19 Test Ordering. J Appl Lab Med 2023; 8:98-105. [PMID: 36610419 DOI: 10.1093/jalm/jfac104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/03/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Despite improving supplies, SARS-CoV-2 nucleic acid amplification tests remain limited during surges and more so given concerns around COVID-19/influenza co-occurrence. Matching clinical guidelines to available supplies ensures resources remain available to meet clinical needs. We report a change in clinician practice after an electronic health record (EHR) order redesign to impact emergency department (ED) testing patterns. METHODS We included all ED visits between December 1, 2021 and January 18, 2022 across a hospital system to assess the impact of EHR order changes on provider behavior 3 weeks before and after the change. The EHR order redesign included embedded symptom-based order guidance. Primary outcomes were the proportion of COVID-19 + flu/respiratory syncytial virus (RSV) testing performed on symptomatic, admitted, and discharged patients, and the proportion of COVID-19 + flu testing on symptomatic, discharged patients. RESULTS A total of 52 215 ED visits were included. For symptomatic, discharged patients, COVID-19 + flu/RSV testing decreased from 11.4 to 5.8 tests per 100 symptomatic visits, and the rate of COVID-19 + flu testing increased from 7.4 to 19.1 before and after the intervention, respectively. The rate of COVID-19 + flu/RSV testing increased from 5.7 to 13.1 tests per 100 symptomatic visits for symptomatic patients admitted to the hospital. All changes were significant (P < 0.0001). CONCLUSIONS A simple EHR order redesign was associated with increased adherence to institutional guidelines for SARS-CoV-2 and influenza testing amidst supply chain limitations necessitating optimal allocation of scarce testing resources. With continually shifting resource availability, clinician education is not sufficient. Rather, system-based interventions embedded within exiting workflows can better align resources and serve testing needs of the community.
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Affiliation(s)
- Rohit B Sangal
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA.,Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Justin Cahill
- Department of Emergency Medicine, Bridgeport Hospital, Bridgeport, CT, USA
| | - Christian M Pettker
- Quality and Safety, Yale New Haven Health, New Haven, CT, USA.,Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - David R Peaper
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
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22
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Reid N, Buchman D, Brown R, Pedersen C, Kozloff N, Stergiopoulos V. The acceptability of financial incentives to support service engagement of adults experiencing homelessness and mental illness: a qualitative study of key stakeholder perspectives Authorship. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:1060-1071. [PMID: 36071341 DOI: 10.1007/s10488-022-01217-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Evidence suggests financial incentives may effectively support service engagement among people experiencing homelessness, but literature related to their acceptability in this population is limited. This study used qualitative methods to explore stakeholder perspectives on the acceptability of using financial incentives to promote service engagement among homeless adults with mental illness. METHODS As part of a larger mixed-methods pragmatic trial of a community-based brief case management program in Toronto, Canada, twenty-two trial participants were purposefully recruited to participate in semi-structured qualitative interviews, and five service providers and seven key informants were purposefully recruited to participate in a focus group and interviews, respectively. Topics included perspectives of acceptability and lived experiences of using financial incentives to support engagement, health and well-being. Data collection occurred between April 2019 and December 2020. Data was audio-recorded and transcribed. Coding and interpretation of data was informed by grounded theory and inductive thematic analysis. RESULTS Stakeholders held diverse views on the acceptability of financial incentives to promote service engagement in this population. Main themes across groups included moralizing recipient motivation; tensions in how best to define and respect autonomy; and consideration of potential unintended consequences for both individuals and the service system. Significant group differences within some themes emerged. CONCLUSION Results highlight ongoing debates over using financial incentives to facilitate service engagement among adults experiencing homelessness and mental illness. Differences in stakeholder perspectives suggest the need for person-centredness in health and research settings, and balancing theoretical risks and long-term goals with likely potential for immediate benefits.
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Affiliation(s)
- Nadine Reid
- Centre for Addiction and Mental Health, 1000 Queen St. W, M6H 1H4, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, M5T 3M6, Toronto, ON, Canada
| | - Daniel Buchman
- Centre for Addiction and Mental Health, 1000 Queen St. W, M6H 1H4, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College St, M5T 3M7, Toronto, ON, Canada
- Joint Centre for Bioethics, University of Toronto, 155 College St, M5T 1P8, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, 60 Leonard Ave, M5T 0S8, Toronto, ON, Canada
| | - Rebecca Brown
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond St, M5B 1W8, Toronto, ON, Canada
| | - Cheryl Pedersen
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond St, M5B 1W8, Toronto, ON, Canada
| | - Nicole Kozloff
- Centre for Addiction and Mental Health, 1000 Queen St. W, M6H 1H4, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, M5T 3M6, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, 250 College St, M5T 1R8, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, 1000 Queen St. W, M6H 1H4, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, M5T 3M6, Toronto, ON, Canada.
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond St, M5B 1W8, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, 250 College St, M5T 1R8, Toronto, ON, Canada.
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Hallek M, Ockenfels A, Wiesen D. Behavioral Economics Interventions to Improve Medical Decision-Making. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:633-639. [PMID: 35912421 PMCID: PMC9764346 DOI: 10.3238/arztebl.m2022.0275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 09/30/2021] [Accepted: 04/07/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND In medicine, a wide gap exists between the medical care that ought to be possible in the light of the current state of medical research and the care that is actually provided. Behavioral biases and noise are two major reasons for this. METHODS We present the findings of a selective literature review and illustrate how interventions based on behavioral economics can help physicians make better decisions and thereby improve treatment outcomes. RESULTS A number of behavioral economics interventions, making use of, for example, default settings, active decision rules, social norms, and self-commitments, may improve physicians' clinical decision-making. Evidence on long-term effects is, however, mostly lacking. CONCLUSION Despite their apparent potential, the application of behavioral economic interventions to improve medical decisionmaking is still in its infancy, particularly in Germany.
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Affiliation(s)
- Michael Hallek
- University Hospital of Cologne, Internal Medicine Clinic I and Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO)
| | - Axel Ockenfels
- Cologne University, Department of Economics, Center for Social and Economic Behavior (C-SEB) and Cluster of Excellence ECONtribute
| | - Daniel Wiesen
- Cologne University, Seminar for General Business Administration and Management in Healthcare and Center for Social and Economic Behavior (C-SEB),*Seminar for General Business Administration and Management in Healthcare University of Cologne Albertus-Magnus-Platz 50931 Cologne
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Fronemann N, Pollmann K, Loh W. Should my robot know what's best for me? Human–robot interaction between user experience and ethical design. AI & SOCIETY 2022. [DOI: 10.1007/s00146-021-01210-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AbstractTo integrate social robots in real-life contexts, it is crucial that they are accepted by the users. Acceptance is not only related to the functionality of the robot but also strongly depends on how the user experiences the interaction. Established design principles from usability and user experience research can be applied to the realm of human–robot interaction, to design robot behavior for the comfort and well-being of the user. Focusing the design on these aspects alone, however, comes with certain ethical challenges, especially regarding the user’s privacy and autonomy. Based on an example scenario of human–robot interaction in elder care, this paper discusses how established design principles can be used in social robotic design. It then juxtaposes these with ethical considerations such as privacy and user autonomy. Combining user experience and ethical perspectives, we propose adjustments to the original design principles and canvass our own design recommendations for a positive and ethically acceptable social human–robot interaction design. In doing so, we show that positive user experience and ethical design may be sometimes at odds, but can be reconciled in many cases, if designers are willing to adjust and amend time-tested design principles.
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Stapleton RD, Ford DW, Sterba KR, Nadig NR, Ades S, Back AL, Carson SS, Cheung KL, Ely J, Kross EK, Macauley RC, Maguire JM, Marcy TW, McEntee JJ, Menon PR, Overstreet A, Ritchie CS, Wendlandt B, Ardren SS, Balassone M, Burns S, Choudhury S, Diehl S, McCown E, Nielsen EL, Paul SR, Rice C, Taylor KK, Engelberg RA. Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients. J Pain Symptom Manage 2022; 63:e621-e632. [PMID: 35595375 PMCID: PMC9179950 DOI: 10.1016/j.jpainsymman.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 01/27/2023]
Abstract
CONTEXT Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree. OBJECTIVES Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families. METHODS This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness. RESULTS Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending. CONCLUSIONS IA is a feasible and reasonable approach to CPR discussions in selected patient populations.
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Affiliation(s)
- Renee D Stapleton
- Pulmonary and Critical Medicine, HSRF 222 (R.D.S), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
| | - Dee W Ford
- Division Director and Professor, Pulmonary, Critical Care, and Sleep Medicine, CSB 816, MSC 630 (D.W.F.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine R Sterba
- Public Health Sciences (K.R.S.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nandita R Nadig
- Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine (N.R.N.), Chicago, Illinois, USA
| | - Steven Ades
- Hematology and Oncology (S.A.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Anthony L Back
- Department of Medicine (A.L.B.), University of Washington, Seattle, Washington, USA
| | - Shannon S Carson
- Pulmonary and Critical Care Medicine (S.S.C.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Katharine L Cheung
- Nephrology (K.L.C.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Janet Ely
- University of Vermont Cancer Center (J.E.), Burlington, Vermont, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care & Sleep Medicine, Co-Director of Cambia Palliative Care Center of Excellence at UW Medicine (E.K.K.), University of Washington, Seattle, Washington, USA
| | | | - Jennifer M Maguire
- Pulmonary and Critical Care Medicine (J.M.M.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Theodore W Marcy
- Pulmonary and Critical Care Medicine (T.W.M.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Jennifer J McEntee
- Internal Medicine and Pediatrics, Palliative Care and Hospice Medicine (J.J.M.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Prema R Menon
- Vertex Pharmaceuticals (P.R.M.), Boston, Massachusetts, USA
| | - Amanda Overstreet
- Geriatrics and Palliative Care (A.O.), Medical University of South Carolina, Charleston, SC
| | | | - Blair Wendlandt
- Pulmonary and Critical Care Medicine (B.W.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sara S Ardren
- University of Vermont Larner College of Medicine (S.S.A.), Burlington, Vermont, USA
| | - Michael Balassone
- Division of Pulmonary and Critical Care Medicine (M.B.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stephanie Burns
- University of Vermont Larner College of Medicine (S.B.), Burlington, Vermont, USA
| | - Summer Choudhury
- North Carolina Translational and Clinical Sciences Institute (S.C.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sandra Diehl
- University of Vermont Medical Center (S.D.), Burlington, Vermont, USA
| | - Ellen McCown
- Spiritual Care (E.M.), University of Washington Medical Center, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine (E.L.N), University of Washington, Seattle, Washington, USA
| | - Sudiptho R Paul
- Pulmonary and Critical Care Medicine (S.R.P., C.R.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Colleen Rice
- Pulmonary and Critical Care Medicine (S.R.P., C.R.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Katherine K Taylor
- Pulmonary, Critical Care, and Sleep Medicine (K.K.T), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ruth A Engelberg
- Pulmonary, Critical Care & Sleep Medicine, Cambia Palliative Care Center of Excellence at UW Medicine (R.A.E.), University of Washington, Seattle, Seattle, Washington, USA
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Mehta SJ, Mallozzi C, Shaw PA, Reitz C, McDonald C, Vandertuyn M, Balachandran M, Kopinsky M, Sevinc C, Johnson A, Ward R, Park SH, Snider CK, Rosin R, Asch DA. Effect of Text Messaging and Behavioral Interventions on COVID-19 Vaccination Uptake: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2216649. [PMID: 35696165 PMCID: PMC9194662 DOI: 10.1001/jamanetworkopen.2022.16649] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE COVID-19 vaccine uptake among urban populations remains low. OBJECTIVE To evaluate whether text messaging with outbound or inbound scheduling and behaviorally informed content might increase COVID-19 vaccine uptake. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial with a factorial design was conducted from April 29 to July 6, 2021, in an urban academic health system. The trial comprised 16 045 patients at least 18 years of age in Philadelphia, Pennsylvania, with at least 1 primary care visit in the past 5 years, or a future scheduled primary care visit within the next 3 months, who were unresponsive to prior outreach. The study was prespecified in the trial protocol, and data were obtained from the intent-to-treat population. INTERVENTIONS Eligible patients were randomly assigned in a 1:20:20 ratio to (1) outbound telephone call only by call center, (2) text message and outbound telephone call by call center to those who respond, or (3) text message, with patients instructed to make an inbound telephone call to a hotline. Patients in groups 2 and 3 were concurrently randomly assigned in a 1:1:1:1 ratio to receive different content: standard messaging, clinician endorsement (eg, "Dr. XXX recommends"), scarcity ("limited supply available"), or endowment framing ("We have reserved a COVID-19 vaccine appointment for you"). MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients who completed the first dose of the COVID-19 vaccine within 1 month, according to the electronic health record. Secondary outcomes were the completion of the first dose within 2 months and completion of the vaccination series within 2 months of initial outreach. Additional outcomes included the percentage of patients with invalid cell phone numbers (wrong number or nontextable), no response to text messaging, the percentage of patients scheduled for the vaccine, text message responses, and the number of telephone calls made by the access center. Analysis was on an intention-to-treat basis. RESULTS Among the 16 045 patients included, the mean (SD) age was 36.9 (11.1) years; 9418 (58.7%) were women; 12 869 (80.2%) had commercial insurance, and 2283 (14.2%) were insured by Medicaid; 8345 (52.0%) were White, 4706 (29.3%) were Black, and 967 (6.0%) were Hispanic or Latino. At 1 month, 14 of 390 patients (3.6% [95% CI, 1.7%-5.4%]) in the outbound telephone call-only group completed 1 vaccine dose, as did 243 of 7890 patients (3.1% [95% CI, 2.7%-3.5%]) in the text plus outbound call group (absolute difference, -0.5% [95% CI, -2.4% to 1.4%]; P = .57) and 253 of 7765 patients (3.3% [95% CI, 2.9%-3.7%]) in the text plus inbound call group (absolute difference, -0.3% [95% CI, -2.2% to 1.6%]; P = .72). Among the 15 655 patients receiving text messaging, 118 of 3889 patients (3.0% [95% CI, 2.5%-3.6%]) in the standard messaging group completed 1 vaccine dose, as did 135 of 3920 patients (3.4% [95% CI, 2.9%-4.0%]) in the clinician endorsement group (absolute difference, 0.4% [95% CI, -0.4% to 1.2%]; P = .31), 100 of 3911 patients (2.6% [95% CI, 2.1%-3.1%]) in the scarcity group (absolute difference, -0.5% [95% CI, -1.2% to 0.3%]; P = .20), and 143 of 3935 patients (3.6% [95% CI, 3.0%-4.2%]) in the endowment group (absolute difference, 0.6% [95% CI, -0.2% to 1.4%]; P = .14). CONCLUSIONS AND RELEVANCE There was no detectable increase in vaccination uptake among patients receiving text messaging compared with telephone calls only or behaviorally informed message content. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04834726.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | | | - Pamela A. Shaw
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Matthew Vandertuyn
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Mohan Balachandran
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Michael Kopinsky
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Christianne Sevinc
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Aaron Johnson
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Robin Ward
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Sae-Hwan Park
- Penn Medicine, University of Pennsylvania, Philadelphia
| | | | - Roy Rosin
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
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Delgado MK. Patient-Centered Default Opioid Orders-A Path Forward for Postoperative Opioid Stewardship. JAMA Netw Open 2022; 5:e2219712. [PMID: 35771581 DOI: 10.1001/jamanetworkopen.2022.19712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M Kit Delgado
- Perelman School of Medicine, Penn Medicine Nudge Unit and the Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
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Lowenstein M, Perrone J, Xiong RA, Snider CK, O’Donnell N, Hermann D, Rosin R, Dees J, McFadden R, Khatri U, Meisel ZF, Mitra N, Delgado MK. Sustained Implementation of a Multicomponent Strategy to Increase Emergency Department-Initiated Interventions for Opioid Use Disorder. Ann Emerg Med 2022; 79:237-248. [PMID: 34922776 PMCID: PMC8860858 DOI: 10.1016/j.annemergmed.2021.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/15/2021] [Accepted: 10/18/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE There is strong evidence supporting emergency department (ED)-initiated buprenorphine for opioid use disorder, but less is known about how to implement this practice. Our aim was to describe implementation, maintenance, and provider adoption of a multicomponent strategy for opioid use disorder treatment in 3 urban, academic EDs. METHODS We conducted a retrospective analysis of electronic health record data for adult patients with opioid use disorder-related visits before (March 2017 to November 2018) and after (December 2018 to July 2020) implementation. We describe patient characteristics, clinical treatment, and process measures over time and conducted an interrupted time series analysis using a patient-level multivariable logistic regression model to assess the association of the interventions with buprenorphine use and other outcomes. Finally, we report provider-level variation in prescribing after implementation. RESULTS There were 2,665 opioid use disorder-related visits during the study period: 28% for overdose, 8% for withdrawal, and 64% for other conditions. Thirteen percent of patients received medications for opioid use disorder during or after their ED visit overall. Following intervention implementation, there were sustained increases in treatment and process measures, with a net increase in total buprenorphine of 20% in the postperiod (95% confidence interval 16% to 23%). In the adjusted patient-level model, there was an immediate increase in the probability of buprenorphine treatment of 24.5% (95% confidence interval 12.1% to 37.0%) with intervention implementation. Seventy percent of providers wrote at least 1 buprenorphine prescription, but provider-level buprenorphine prescribing ranged from 0% to 61% of opioid use disorder-related encounters. CONCLUSION A combination of strategies to increase ED-initiated opioid use disorder treatment was associated with sustained increases in treatment and process measures. However, adoption varied widely among providers, suggesting that additional strategies are needed for broader uptake.
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Affiliation(s)
- Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Ruiying Aria Xiong
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | | | - Nicole O’Donnell
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Davis Hermann
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Roy Rosin
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Julie Dees
- Family Service Association of Bucks County, Langhorne, PA
| | - Rachel McFadden
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Utsha Khatri
- Department of Emergency Medicine, Mount Sinai Icahn School of Medicine, New York, NY
| | - Zachary F. Meisel
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Nandita Mitra
- Department: Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - M. Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
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Donadee C, Cohen-Melamed M, Delgado E, Gunn SR. Improving delivery of low tidal volume ventilation in 10 ICUs. BMJ Open Qual 2022; 11:bmjoq-2021-001343. [PMID: 35105549 PMCID: PMC8808457 DOI: 10.1136/bmjoq-2021-001343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Abstract
Low tidal volume ventilation (LTVV) is standard of care for mechanically ventilated patients with acute respiratory distress syndrome and has been shown to improve outcomes in the general mechanically ventilated population. Despite these improved outcomes, in clinical practice the LTVV standard of care is often not met. We aimed to increase compliance with LTVV in mechanically ventilated patients in 10 intensive care units at 3 hospitals within the University of Pittsburgh School of Medicine Department of Critical Care Medicine. Four Plan-Do-Study-Act (PDSA) cycles were implemented to improve compliance with LTVV. Initial compliance rates of 40.6%–60.1% improved to 91%–96% by the end of the fourth PDSA cycle. The most impactful step in the intervention was providing education and giving responsibility of selecting the tidal volume to the respiratory therapist. The overall intervention resulted in improved compliance with LTVV that has been sustained for multiple years after our active PDSA cycles.
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Affiliation(s)
- Chenell Donadee
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark Cohen-Melamed
- Respiratory Care Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Edgar Delgado
- Respiratory Care Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott R Gunn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Lowenstein M, McFadden R, Abdel-Rahman D, Perrone J, Meisel ZF, O'Donnell N, Wood C, Solomon G, Beidas R, Delgado MK. Redesign of Opioid Use Disorder Screening and Treatment in the ED. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 2022; 3:10.1056/CAT.21.0297. [PMID: 37961066 PMCID: PMC10641724 DOI: 10.1056/cat.21.0297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Traditionally, patients with opioid use disorder (OUD) seen in EDs have been medically cleared, discharged, and left to navigate a complex treatment system after discharge. Replacing this system of care requires reimagining the ED visit to promote best practices, including starting treatment with lifesaving medications for OUD in the ED. In this article, the authors present stakeholder-informed design of strategies for implementation of evidence-based ED OUD care at Penn Medicine. They used a participatory design approach to incorporate insights from diverse clinician groups in an iterative fashion to develop new processes of care that identified patients early to initiate OUD care pathways. Their design process led to the development of a nurse-driven protocol with OUD screening in ED triage coupled with automated prompts to both nurses and physicians or advanced practice providers to perform assessment and treatment of OUD and to deliver evidence-based treatment interventions.
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Affiliation(s)
- Margaret Lowenstein
- Assistant Professor of Medicine, Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel McFadden
- Emergency Nurse, Hospital of the University of Pennsylvania and Center F Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dina Abdel-Rahman
- Project Manager, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeanmarie Perrone
- Professor of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Director, Division of Medical Toxicology and Addiction Medicine Initiatives, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Founding Director, Penn Center for Addiction Medicine and Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Zachary F Meisel
- Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Associate Professor of Emergency Medicine, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole O'Donnell
- Certified Recovery Specialist, Penn Center for Addiction Medicine and Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christian Wood
- Medical Student, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gabrielle Solomon
- Student, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rinad Beidas
- Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Associate Professor of Psychiatry, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Director, Penn Medicine Nudge Unit and the Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Director, Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - M Kit Delgado
- Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Assistant Professor, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Associate Director, Penn Medicine Nudge Unit and the Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Director, University of Pennsylvania Behavioral Science and Analytics for Injury Reduction, Philadelphia, Pennsylvania, USA
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Beyond the Do-not-resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients. Anesthesiology 2021; 135:781-787. [PMID: 34499085 DOI: 10.1097/aln.0000000000003937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, "full code" is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.
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Beraldo S, Karpus J. Nudging to donate organs: do what you like or like what we do? MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:329-340. [PMID: 33733389 PMCID: PMC8349348 DOI: 10.1007/s11019-021-10007-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 06/12/2023]
Abstract
An effective method to increase the number of potential cadaveric organ donors is to make people donors by default with the option to opt out. This non-coercive public policy tool to influence people's choices is often justified on the basis of the as-judged-by-themselves principle: people are nudged into choosing what they themselves truly want. We review three often hypothesized reasons for why defaults work and argue that the as-judged-by-themselves principle may hold only in two of these cases. We specify further conditions for when the principle can hold in these cases and show that whether those conditions are met is often unclear. We recommend ways to expand nationwide surveys to identify the actual reasons for why defaults work and discuss mandated choice policy as a viable solution to many arising conundrums.
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Affiliation(s)
- Sergio Beraldo
- Department of Economics and Statistics, University of Napoli, Naples, Italy
| | - Jurgis Karpus
- Faculty of Philosophy, Philosophy of Science and the Study of Religion, LMU Munich, Munich, Germany.
- Faculty of Psychology and Educational Sciences, General and Experimental Psychology, LMU Munich, Munich, Germany.
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Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol. Ann Am Thorac Soc 2021; 18:336-346. [PMID: 32936675 DOI: 10.1513/annalsats.202002-088sd] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).
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Kerlin MP, Small D, Fuchs BD, Mikkelsen ME, Wang W, Tran T, Scott S, Belk A, Silvestri JA, Klaiman T, Halpern SD, Beidas RS. Implementing nudges to promote utilization of low tidal volume ventilation (INPUT): a stepped-wedge, hybrid type III trial of strategies to improve evidence-based mechanical ventilation management. Implement Sci 2021; 16:78. [PMID: 34376233 PMCID: PMC8353429 DOI: 10.1186/s13012-021-01147-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/25/2021] [Indexed: 11/19/2022] Open
Abstract
Background Behavioral economic insights have yielded strategies to overcome implementation barriers. For example, default strategies and accountable justification strategies have improved adherence to best practices in clinical settings. Embedding such strategies in the electronic health record (EHR) holds promise for simple and scalable approaches to facilitating implementation. A proven-effective but under-utilized treatment for patients who undergo mechanical ventilation involves prescribing low tidal volumes, which protects the lungs from injury. We will evaluate EHR-based implementation strategies grounded in behavioral economic theory to improve evidence-based management of mechanical ventilation. Methods The Implementing Nudges to Promote Utilization of low Tidal volume ventilation (INPUT) study is a pragmatic, stepped-wedge, hybrid type III effectiveness implementation trial of three strategies to improve adherence to low tidal volume ventilation. The strategies target clinicians who enter electronic orders and respiratory therapists who manage the mechanical ventilator, two key stakeholder groups. INPUT has five study arms: usual care, a default strategy within the mechanical ventilation order, an accountable justification strategy within the mechanical ventilation order, and each of the order strategies combined with an accountable justification strategy within flowsheet documentation. We will create six matched pairs of twelve intensive care units (ICUs) in five hospitals in one large health system to balance patient volume and baseline adherence to low tidal volume ventilation. We will randomly assign ICUs within each matched pair to one of the order panels, and each pair to one of six wedges, which will determine date of adoption of the order panel strategy. All ICUs will adopt the flowsheet documentation strategy 6 months afterwards. The primary outcome will be fidelity to low tidal volume ventilation. The secondary effectiveness outcomes will include in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay, and occurrence of potential adverse events. Discussion This stepped-wedge, hybrid type III trial will provide evidence regarding the role of EHR-based behavioral economic strategies to improve adherence to evidence-based practices among patients who undergo mechanical ventilation in ICUs, thereby advancing the field of implementation science, as well as testing the effectiveness of low tidal volume ventilation among broad patient populations. Trial registration ClinicalTrials.gov, NCT04663802. Registered 11 December 2020.
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Affiliation(s)
- Meeta Prasad Kerlin
- Pulmonary, Critical Care and Allergy Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Dylan Small
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA
| | - Barry D Fuchs
- Pulmonary, Critical Care and Allergy Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark E Mikkelsen
- Pulmonary, Critical Care and Allergy Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wei Wang
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Teresa Tran
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefania Scott
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aerielle Belk
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jasmine A Silvestri
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tamar Klaiman
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D Halpern
- Pulmonary, Critical Care and Allergy Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rinad S Beidas
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA
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Jenssen BP, Schnoll R, Beidas R, Bekelman J, Bauer AM, Scott C, Evers-Casey S, Nicoloso J, Gabriel P, Asch DA, Buttenheim A, Chen J, Melo J, Shulman LN, Clifton ABW, Lieberman A, Salam T, Zentgraf K, Rendle KA, Chaiyachati K, Shelton R, Wileyto EP, Ware S, Leone F. Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke. Implement Sci 2021; 16:72. [PMID: 34266468 PMCID: PMC8281481 DOI: 10.1186/s13012-021-01139-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. METHODS A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. DISCUSSION This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. TRIAL REGISTRATION Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021.
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Affiliation(s)
- Brian P. Jenssen
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Robert Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Rinad Beidas
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, USA
- Penn Implementation Science Center (PISCE@LDI), Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Justin Bekelman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Penn Implementation Science Center (PISCE@LDI), Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Anna-Marika Bauer
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Callie Scott
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Sarah Evers-Casey
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jody Nicoloso
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Peter Gabriel
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - David A. Asch
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Alison Buttenheim
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jessica Chen
- University of Pennsylvania Health System, Philadelphia, USA
| | - Julissa Melo
- University of Pennsylvania Health System, Philadelphia, USA
| | - Lawrence N. Shulman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Alicia B. W. Clifton
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Adina Lieberman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Tasnim Salam
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Kelly Zentgraf
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Katharine A. Rendle
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Krisda Chaiyachati
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Rachel Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, USA
| | - E. Paul Wileyto
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Sue Ware
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Frank Leone
- Pulmonary, Allergy, & Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Sacks OA, Sachs TE. Is Preoperative Consultation the Right Time for Advance Care Planning? JAMA Surg 2021; 156:e211534. [PMID: 33978694 DOI: 10.1001/jamasurg.2021.1534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Olivia A Sacks
- Department of Surgical Oncology, Boston Medical Center, Boston, Massachusetts
| | - Teviah E Sachs
- Department of Surgical Oncology, Boston Medical Center, Boston, Massachusetts
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Huf SW, Asch DA, Volpp KG, Reitz C, Mehta SJ. Text Messaging and Opt-out Mailed Outreach in Colorectal Cancer Screening: a Randomized Clinical Trial. J Gen Intern Med 2021; 36:1958-1964. [PMID: 33511567 PMCID: PMC8298623 DOI: 10.1007/s11606-020-06415-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Routine screening reduces colorectal cancer mortality, but screening rates fall below national targets and are particularly low in underserved populations. OBJECTIVE To compare the effectiveness of a single text message outreach to serial text messaging and mailed fecal home test kits on colorectal cancer screening rates. DESIGN A two-armed randomized clinical trial. PARTICIPANTS An urban community health center in Philadelphia. Adults aged 50-74 who were due for colorectal cancer screening had at least one visit to the practice in the previously year, and had a cell phone number recorded. INTERVENTIONS Participants were randomized (1:1 ratio). Individuals in the control arm were sent a simple text message reminder as per usual practice. Those in the intervention arm were sent a pre-alert text message offering the options to opt-out of receiving a mailed fecal immunochemical test (FIT) kit, followed by up to three behaviorally informed text message reminders. MAIN MEASURES The primary outcome was participation in colorectal cancer screening at 12 weeks. The secondary outcome was the FIT kit return rate at 12 weeks. KEY RESULTS Four hundred forty participants were included. The mean age was 57.4 years (SD ± 6.1). 63.4% were women, 87.7% were Black, 19.1% were uninsured, and 49.6% were Medicaid beneficiaries. At 12 weeks, there was an absolute 17.3 percentage point increase in colorectal cancer screening in the intervention arm (19.6%), compared to the control arm (2.3%, p < 0.001). There was an absolute 17.7 percentage point increase in FIT kit return in the intervention arm (19.1%) compared to the control arm (1.4%, p < 0.001). CONCLUSIONS Serial text messaging with opt-out mailed FIT kit outreach can substantially improve colorectal cancer screening rates in an underserved population. TRIAL REGISTRATION clinicaltrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03479645 ).
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Affiliation(s)
- Sarah W Huf
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. .,The Commonwealth Fund, Harkness Fellowship, New York City, NY, USA. .,Department of Surgery and Cancer, Imperial College London, London, UK. .,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - David A Asch
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Kevin G Volpp
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Catherine Reitz
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Morris AH, Stagg B, Lanspa M, Orme J, Clemmer TP, Weaver LK, Thomas F, Grissom CK, Hirshberg E, East TD, Wallace CJ, Young MP, Sittig DF, Pesenti A, Bombino M, Beck E, Sward KA, Weir C, Phansalkar SS, Bernard GR, Taylor Thompson B, Brower R, Truwit JD, Steingrub J, Duncan Hite R, Willson DF, Zimmerman JJ, Nadkarni VM, Randolph A, Curley MAQ, Newth CJL, Lacroix J, Agus MSD, Lee KH, deBoisblanc BP, Scott Evans R, Sorenson DK, Wong A, Boland MV, Grainger DW, Dere WH, Crandall AS, Facelli JC, Huff SM, Haug PJ, Pielmeier U, Rees SE, Karbing DS, Andreassen S, Fan E, Goldring RM, Berger KI, Oppenheimer BW, Wesley Ely E, Gajic O, Pickering B, Schoenfeld DA, Tocino I, Gonnering RS, Pronovost PJ, Savitz LA, Dreyfuss D, Slutsky AS, Crapo JD, Angus D, Pinsky MR, James B, Berwick D. Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. J Am Med Inform Assoc 2021; 28:1330-1344. [PMID: 33594410 PMCID: PMC8661391 DOI: 10.1093/jamia/ocaa294] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/10/2020] [Indexed: 02/05/2023] Open
Abstract
Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention-the starting point for delivery of "All the right care, but only the right care," an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.
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Affiliation(s)
- Alan H Morris
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
| | - Brian Stagg
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
| | - Michael Lanspa
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - James Orme
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Terry P Clemmer
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
- Emeritus
| | - Lindell K Weaver
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Frank Thomas
- Department of Value Engineering, University of Utah Hospitals and Clinics, Salt Lake City, Utah, USA
- Emeritus
| | - Colin K Grissom
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ellie Hirshberg
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas D East
- SYNCRONYS, and University of New Mexico Health Sciences Library & Informatics, Albuquerque, New Mexico, USA
| | - Carrie Jane Wallace
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
- Emeritus
| | - Michael P Young
- Critical Care Division, Renown Medical Center, School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, USA
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care Medicine, ASST-Monza San Gerardo Hospital, Milan, Italy
| | - Eduardo Beck
- Ospedale di Desio—ASST Monza, UOC Anestesia e Rianimazione, Milan, Italy
| | | | - Charlene Weir
- Department of Biomedical Informatics
- School of Nursing
| | | | - Gordon R Bernard
- Pulmonary, Critical Care, and Allergy Division, Department of Internal Medicine
| | - B Taylor Thompson
- Pulmonary, Critical Care, and Sleep Division , Department of Internal Medicine
| | - Roy Brower
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathon D Truwit
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jay Steingrub
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - R Duncan Hite
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Douglas F Willson
- Division of Pediatric Critical Care, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vinay M Nadkarni
- Department of Anesthesia and Critical Care Medicine
- Department of Pediatrics, Perelman School of Medicine
| | | | - Martha A. Q Curley
- Department of Pediatrics, Perelman School of Medicine
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher J. L Newth
- Department of Pediatrics, University of Southern California, Los Angeles, California, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | | | - Kang H Lee
- Asian American Liver Centre, Gleneagles Hospital, Singapore, Singapore
| | - Bennett P deBoisblanc
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | | | | | - Anthony Wong
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | - David W Grainger
- Department of Biomedical Engineering and Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah
| | - Willard H Dere
- Department of Biomedical Engineering and Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah
| | - Alan S Crandall
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
| | - Julio C Facelli
- Department of Biomedical Informatics
- Center for Clinical and Translational Science, School of Medicine
| | | | | | - Ulrike Pielmeier
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Stephen E Rees
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Dan S Karbing
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Steen Andreassen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Eddy Fan
- Institute of Health Policy, Management and Evaluation
| | - Roberta M Goldring
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - Kenneth I Berger
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - Beno W Oppenheimer
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - E Wesley Ely
- Pulmonary, Critical Care, and Allergy Division, Department of Internal Medicine
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center
- Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Ognjen Gajic
- Pulmonary , Critical Care, and Sleep Division, Department of Internal Medicine
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - David A Schoenfeld
- Department of Biostatistics, T.H. Chan School of Public Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Irena Tocino
- Department of Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Russell S Gonnering
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Peter J Pronovost
- Critical Care, Department of Anesthesia, Chief Clinical Transformation Officer, University Hospitals, Highland Hills, Case Western Reserve University, Cleveland, OH, USA
| | - Lucy A Savitz
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Didier Dreyfuss
- Assistance Publique – Hôpitaux de Paris, Université de Paris, INSERM unit UMR S_1155 (Common and Rare Kidney Diseases), Sorbonne Université, Paris, France
| | - Arthur S Slutsky
- Keenan Research Center, Li Ka Shing Knowledge Institute / ST. Michaels' Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - James D Crapo
- Department of Internal Medicine, National Jewish Health, Denver, Colorado, USA
| | - Derek Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brent James
- Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Donald Berwick
- Institute for Healthcare Improvement, Boston, Massachusetts, USA
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Hunt TC, Ambrose JP, Haaland B, Kawamoto K, Dechet CB, Lowrance WT, Hanson HA, O'Neil BB. Decision fatigue in low-value prostate cancer screening. Cancer 2021; 127:3343-3353. [PMID: 34043813 DOI: 10.1002/cncr.33644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/22/2021] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Low-value prostate-specific antigen (PSA) testing is common yet contributes substantial waste and downstream patient harm. Decision fatigue may represent an actionable target to reduce low-value urologic care. The objective of this study was to determine whether low-value PSA testing patterns by outpatient clinicians are consistent with decision fatigue. METHODS Outpatient appointments for adult men without prostate cancer were identified at a large academic health system from 2011 through 2018. The authors assessed the association of appointment time with the likelihood of PSA testing, stratified by patient age and appropriateness of testing based on clinical guidelines. Appointments included those scheduled between 8:00 am and 4:59 pm, with noon omitted. Urologists were examined separately from other clinicians. RESULTS In 1,581,826 outpatient appointments identified, the median patient age was 54 years (interquartile range, 37-66 years), 1,256,152 participants (79.4%) were White, and 133,693 (8.5%) had family history of prostate cancer. PSA testing would have been appropriate in 36.8% of appointments. Clinicians ordered testing in 3.6% of appropriate appointments and in 1.8% of low-value appointments. Appropriate testing was most likely at 8:00 am (reference group). PSA testing declined through 11:00 am (odds ratio [OR], 0.57; 95% CI, 0.50-0.64) and remained depressed through 4:00 pm (P < .001). Low-value testing was overall less likely (P < .001) and followed a similar trend, declining steadily from 8:00 am (OR, 0.48; 95% CI, 0.42-0.56) through 4:00 pm (P < .001; OR, 0.23; 95% CI, 0.18-0.30). Testing patterns in urologists were noticeably different. CONCLUSIONS Among most clinicians, outpatient PSA testing behaviors appear to be consistent with decision fatigue. These findings establish decision fatigue as a promising, actionable target for reducing wasteful and low-value practices in routine urologic care. LAY SUMMARY Decision fatigue causes poorer choices to be made with repetitive decision making. This study used medical records to investigate whether decision fatigue influenced clinicians' likelihood of ordering a low-value screening test (prostate-specific antigen [PSA]) for prostate cancer. In more than 1.5 million outpatient appointments by adult men without prostate cancer, the chances of both appropriate and low-value PSA testing declined as the clinic day progressed, with a larger decline for appropriate testing. Testing patterns in urologists were different from those reported by other clinicians. The authors conclude that outpatient PSA testing behaviors appear to be consistent with decision fatigue among most clinicians, and interventions may reduce wasteful testing and downstream patient harms.
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Affiliation(s)
- Trevor C Hunt
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jacob P Ambrose
- Population Sciences, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Benjamin Haaland
- Division of Biostatistics, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Christopher B Dechet
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - William T Lowrance
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Heidi A Hanson
- Population Sciences, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Brock B O'Neil
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Mehta SJ, Day SC, Norris AH, Sung J, Reitz C, Wollack C, Snider CK, Shaw PA, Asch DA. Behavioral interventions to improve population health outreach for hepatitis C screening: randomized clinical trial. BMJ 2021; 373:n1022. [PMID: 34006604 PMCID: PMC8129827 DOI: 10.1136/bmj.n1022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate whether opt out framing, messaging incorporating behavioral science concepts, or electronic communication increases the uptake of hepatitis C virus (HCV) screening in patients born between 1945 and 1965. DESIGN Pragmatic randomized controlled trial. SETTING 43 primary care practices from one academic health system (Philadelphia, PA, USA) between April 2019 and May 2020. PARTICIPANTS Patients born between 1945 and 1965 with no history of screening and at least two primary care visits in the two years before the enrollment period. INTERVENTIONS This multilevel trial was divided into two studies. Substudy A included 1656 eligible patients of 17 primary care clinicians who were randomized in a 1:1 ratio to a mailed letter about HCV screening (letter only), or a similar letter with a laboratory order for HCV screening (letter+order). Substudy B included the remaining 19 837 eligible patients followed by 417 clinicians. Active electronic patient portal users were randomized 1:5 to receive a mailed letter about HCV screening (letter), or an electronic patient portal message with similar content (patient portal); inactive patient portal users were mailed a letter. In a factorial design, patients in substudy B were also randomized 1:1 to receive standard content (usual care), or content based on principles of social norming, anticipated regret, reciprocity, and commitment (behavioral content). MAIN OUTCOME MEASURES Proportion of patients who completed HCV testing within four months. RESULTS 21 303 patients were included in the intention-to-treat analysis. Among the 1642 patients in substudy A, 19.2% (95% confidence interval 16.5% to 21.9%) completed screening in the letter only arm and 43.1% (39.7% to 46.4%) in the letter+order arm (P<0.001). Among the 19 661 patients in substudy B, 14.6% (13.9% to 15.3%) completed screening with usual care content and 13.6% (13.0% to 14.3%) with behavioral science content (P=0.06). Among active patient portal users, 17.8% (16.0% to 19.5%) completed screening after receiving a letter and 13.8% (13.1% to 14.5%) after receiving a patient portal message (P<0.001). CONCLUSIONS Opt out framing and effort reduction by including a signed laboratory order with outreach increased screening for HCV. Behavioral science messaging content did not increase uptake, and mailed letters achieved a greater response rate than patient portal messages. TRIAL REGISTRATION ClinicalTrials.gov NCT03712553.
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Affiliation(s)
- Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Day
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne H Norris
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica Sung
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
| | - Colin Wollack
- Information Services, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher K Snider
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
| | - Pamela A Shaw
- Department of Clinical Epidemiology, Biostatistics, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
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Mozer CL, Bhagat PH, Seward SA, Mason NR, Anderson SL, Byron M, Peirce LB, Konold V, Kumar M, Arora VM, Orlov NM. Optimizing Oral Medication Schedules for Inpatient Sleep: A Quality Improvement Intervention. Hosp Pediatr 2021; 11:327-333. [PMID: 33731336 DOI: 10.1542/hpeds.2020-002261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Hospitalized children experience frequent nighttime awakenings. Oral medications are commonly administered around the clock despite the comparable efficacy of daytime administration schedules, which promote sleep. With this study, we evaluated the effectiveness of a quality improvement initiative to increase the proportion of sleep-friendly antibiotic administration schedules. METHODS Interprofessional stakeholders modified computerized provider order entry defaults for 4 oral antibiotic medications, from around the clock to administration occurring exclusively during waking hours. Additionally, care-team members received targeted education. Outcome measures included the proportion of sleep-friendly administration schedules and patient caregiver-reported disruptions to sleep. Pre- and posteducation surveys were used to evaluate education effectiveness. Balancing measures were missed antibiotic doses and related escalations of care. RESULTS Interrupted time series analysis revealed a 72% increase (interceptpre: 18%; interceptpost: 90%; 95% confidence interval: 65%-79%; P < .001) in intercept for percentage of orders with sleep-friendly administration schedules (orders: n pre = 1014 and n post = 649). Compared with preeducation surveys, care-team members posteducation were more likely to agree that oral medications scheduled around the clock cause sleep disruption (resident: 71% pre, 90% post [P = .01]; nurse: 63% pre, 79% post [P = .03]). Although sleep-friendly orders increased, patient caregivers reported an increase in sleep disruption due to medications (pre 28%, post 46%; P < .001). CONCLUSIONS A simple, low-cost intervention of computerized provider order entry default modifications and education can increase the proportion of sleep-friendly oral antibiotic administration schedules for hospitalized children. Patient perception of sleep is impacted by multiple factors and often does not align with objective data. An increased focus on improving sleep during hospitalization may result in heightened awareness of disruptions.
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Affiliation(s)
- Christine L Mozer
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois
| | | | - Sarah A Seward
- IS Technology and Applications, Children's Wisconsin, West Allis, Wisconsin
| | - Noah R Mason
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois
| | | | - Maxx Byron
- Section of General Internal Medicine, Department of Medicine
| | - Leah B Peirce
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | - Victoria Konold
- Infectious Diseases and Virology, Seattle Children's Hospital, Seattle, Washington
| | - Madan Kumar
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois.,Sections of Infectious Diseases and
| | - Vineet M Arora
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois.,Section of General Internal Medicine, Department of Medicine
| | - Nicola M Orlov
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; .,Pediatric Hospital Medicine, Department of Pediatrics and
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Ohde JW, Master Z, Tilburt JC, Warner DO. Presumed Consent With Opt-Out: An Ethical Consent Approach to Automatically Refer Patients With Cancer to Tobacco Treatment Services. J Clin Oncol 2021; 39:876-880. [PMID: 33439692 DOI: 10.1200/jco.20.03180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Joshua W Ohde
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN
| | - Zubin Master
- Biomedical Ethics Research Program and Center for Regenerative Medicine, Mayo Clinic, Rochester, MN
| | - Jon C Tilburt
- Biomedical Ethics Research Program; Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Moss AH, Navia RO. Should we recommend dialysis for older patients with kidney failure and dementia? J Am Geriatr Soc 2021; 69:1105-1107. [PMID: 33666942 DOI: 10.1111/jgs.17076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Alvin H Moss
- Section of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia, USA.,Section of Geriatrics and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - R Osvaldo Navia
- Section of Geriatrics and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, USA
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Rubins D, Boxer R, Landman A, Wright A. Effect of default order set settings on telemetry ordering. J Am Med Inform Assoc 2021; 26:1488-1492. [PMID: 31504592 DOI: 10.1093/jamia/ocz137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/08/2019] [Accepted: 07/13/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To investigate the effects of adjusting the default order set settings on telemetry usage. MATERIALS AND METHODS We performed a retrospective, controlled, before-after study of patients admitted to a house staff medicine service at an academic medical center examining the effect of changing whether the admission telemetry order was pre-selected or not. Telemetry orders on admission and subsequent orders for telemetry were monitored pre- and post-change. Two other order sets that had no change in their default settings were used as controls. RESULTS Between January 1, 2017 and May 1, 2018, there were 1, 163 patients admitted using the residency-customized version of the admission order set which initially had telemetry pre-selected. In this group of patients, there was a significant decrease in telemetry ordering in the post-intervention period: from 79.1% of patients in the 8.5 months prior ordered to have telemetry to 21.3% of patients ordered in the 7.5 months after (χ2 = 382; P < .001). There was no significant change in telemetry usage among patients admitted using the two control order sets. DISCUSSION Default settings have been shown to affect clinician ordering behavior in multiple domains. Consistent with prior findings, our study shows that changing the order set settings can significantly affect ordering practices. Our study was limited in that we were unable to determine if the change in ordering behavior had significant impact on patient care or safety. CONCLUSION Decisions about default selections in electronic health record order sets can have significant consequences on ordering behavior.
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Affiliation(s)
- David Rubins
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA and
| | - Robert Boxer
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA and
| | - Adam Landman
- Harvard Medical School, Boston, Massachusetts, USA and.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adam Wright
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA and
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45
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Lamprell K, Tran Y, Arnolda G, Braithwaite J. Nudging clinicians: A systematic scoping review of the literature. J Eval Clin Pract 2021; 27:175-192. [PMID: 32342613 DOI: 10.1111/jep.13401] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND While the quality of medical care delivered by physicians can be very good, it can also be inconsistent and feature behaviours that are entrenched despite updated information and evidence. The "nudge" paradigm for behaviour change is being used to bring clinical practice in line with desired standards. The premise is that behaviour can be voluntarily shifted by making particular choices instinctively appealing. We reviewed studies that are explicit about their use of nudge theory in influencing clinician behaviour. METHODS Databases were searched from April 2008 (the publication date of the book that introduced nudge theory to a wider audience) to November 2018, inclusive. The search strategy and narrative review of results addressed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. RESULTS 22 studies were identified. Randomized trials or pre-post comparisons were generally used in community-based settings; single-site pre-post studies were favoured in hospitals. The studies employed eight intervention types: active choice; patient chart redesign; default and default alerts; partitioning of prescription menus; audit and feedback; commitment messages; peer comparisons; and redirection of workflow. Three core cognitive factors underpinned the eight interventions: bias towards prominent choices (salience); predisposition to social norms; and bias towards time or cost savings. CONCLUSIONS Published studies that are explicit about their use of nudge theory are few in number and diverse in their settings, targets, and results. Default and chart re-design interventions reported the most substantial improvements in adherence to evidence and guideline-based practice. Studies that are explicit in their use of nudge theory address the widespread failure of clinical practice studies to identify theoretical frameworks for interventions. However, few studies identified in our review engaged in research to understand the contextual and site-specific barriers to a desired behaviour before designing a nudge intervention.
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Affiliation(s)
- Klay Lamprell
- Macquarie University, Australian Institute of Health Innovation, Sydney, New South Wales, Australia
| | - Yvonne Tran
- Macquarie University, Australian Institute of Health Innovation, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Macquarie University, Australian Institute of Health Innovation, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Macquarie University, Australian Institute of Health Innovation, Sydney, New South Wales, Australia
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Reese PP, Glanz K, Shah A, Mussell A, Levsky S, Shuda L, Shults J, Kessler JB. A Randomized Trial of Theory-Informed Appeals for Organ Donor Registration Using Internet Advertisements. Kidney Int Rep 2020; 5:2238-2245. [PMID: 33305117 PMCID: PMC7710840 DOI: 10.1016/j.ekir.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction Many people do not register as organ donors. We developed 5 different brief appeals for organ donation that were disseminated online. The content was informed by theories of behavior change and studies of the specific cognitive barriers to organ donor registration. Methods One message was a persuasive narrative about a transplant recipient. Another message promoted the idea that organ donor registration is a social norm. The knowledge-based message communicated that 1 donor could improve the lives of 50 people. The message on reciprocity offered a free organ donation wristband, whether or not the participant registered as a donor. The message on control simply encouraged organ donation. Using Google AdWords, the messages were deployed randomly as banners of different sizes on diverse online sites and carried a link to an organ donor registration site. We measured clicks, page visits, and organ donor registrations. Results There were 5,156,048 impressions and 25,001 total clicks, a click-through rate of 0.49%. The messages on control and reciprocity both had the highest click-through rates of 0.51%. A total of 152 unique individuals requested wristbands and there were 52 total organ donor registration events. The message on reciprocity had the highest number of organ donor registrations (n = 18). Conclusion Online organ donation messages rapidly generated substantial attention through clicks, but no message led to a meaningful number of organ donor registrations. Future research may focus on effectively capturing the attention of viewers through social networks or other convenient online venues with less competition for attention than Internet banners.
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Affiliation(s)
- Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Correspondence: P.P. Reese, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 917 Blockley Hall, 423 Guardian Drive, Philadelphia, Pennsylvania 19104, USA.
| | - Karen Glanz
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ankur Shah
- Division of Nephrology, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Adam Mussell
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Simona Levsky
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Lester Shuda
- Philly Marketing Labs, King of Prussia, Pennsylvania, USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Judd B. Kessler
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Manz CR, Parikh RB, Small DS, Evans CN, Chivers C, Regli SH, Hanson CW, Bekelman JE, Rareshide CAL, O'Connor N, Schuchter LM, Shulman LN, Patel MS. Effect of Integrating Machine Learning Mortality Estimates With Behavioral Nudges to Clinicians on Serious Illness Conversations Among Patients With Cancer: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Oncol 2020; 6:e204759. [PMID: 33057696 PMCID: PMC7563672 DOI: 10.1001/jamaoncol.2020.4759] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Serious illness conversations (SICs) are structured conversations between clinicians and patients about prognosis, treatment goals, and end-of-life preferences. Interventions that increase the rate of SICs between oncology clinicians and patients may improve goal-concordant care and patient outcomes. Objective To determine the effect of a clinician-directed intervention integrating machine learning mortality predictions with behavioral nudges on motivating clinician-patient SICs. Design, Setting, and Participants This stepped-wedge cluster randomized clinical trial was conducted across 20 weeks (from June 17 to November 1, 2019) at 9 medical oncology clinics (8 subspecialty oncology and 1 general oncology clinics) within a large academic health system in Pennsylvania. Clinicians at the 2 smallest subspecialty clinics were grouped together, resulting in 8 clinic groups randomly assigned to the 4 intervention wedge periods. Included participants in the intention-to-treat analyses were 78 oncology clinicians who received SIC training and their patients (N = 14 607) who had an outpatient oncology encounter during the study period. Interventions (1) Weekly emails to oncology clinicians with SIC performance feedback and peer comparisons; (2) a list of up to 6 high-risk patients (≥10% predicted risk of 180-day mortality) scheduled for the next week, estimated using a validated machine learning algorithm; and (3) opt-out text message prompts to clinicians on the patient's appointment day to consider an SIC. Clinicians in the control group received usual care consisting of weekly emails with cumulative SIC performance. Main Outcomes and Measures Percentage of patient encounters with an SIC in the intervention group vs the usual care (control) group. Results The sample consisted of 78 clinicians and 14 607 patients. The mean (SD) age of patients was 61.9 (14.2) years, 53.7% were female, and 70.4% were White. For all encounters, SICs were conducted among 1.3% in the control group and 4.6% in the intervention group, a significant difference (adjusted difference in percentage points, 3.3; 95% CI, 2.3-4.5; P < .001). Among 4124 high-risk patient encounters, SICs were conducted among 3.6% in the control group and 15.2% in the intervention group, a significant difference (adjusted difference in percentage points, 11.6; 95% CI, 8.2-12.5; P < .001). Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial, an intervention that delivered machine learning mortality predictions with behavioral nudges to oncology clinicians significantly increased the rate of SICs among all patients and among patients with high mortality risk who were targeted by the intervention. Behavioral nudges combined with machine learning mortality predictions can positively influence clinician behavior and may be applied more broadly to improve care near the end of life. Trial Registration ClinicalTrials.gov Identifier: NCT03984773.
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Affiliation(s)
- Christopher R Manz
- Department of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ravi B Parikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Dylan S Small
- Wharton School of the University of Pennsylvania, Philadelphia
| | - Chalanda N Evans
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Medicine Nudge Unit, Philadelphia, Pennsylvania
| | - Corey Chivers
- University of Pennsylvania Health System, Philadelphia
| | - Susan H Regli
- University of Pennsylvania Health System, Philadelphia
| | | | - Justin E Bekelman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Charles A L Rareshide
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Medicine Nudge Unit, Philadelphia, Pennsylvania
| | - Nina O'Connor
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lynn M Schuchter
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Lawrence N Shulman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Mitesh S Patel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,Penn Medicine Nudge Unit, Philadelphia, Pennsylvania
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Mehta SJ, Hume E, Troxel AB, Reitz C, Norton L, Lacko H, McDonald C, Freeman J, Marcus N, Volpp KG, Asch DA. Effect of Remote Monitoring on Discharge to Home, Return to Activity, and Rehospitalization After Hip and Knee Arthroplasty: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2028328. [PMID: 33346847 PMCID: PMC7753899 DOI: 10.1001/jamanetworkopen.2020.28328] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/10/2020] [Indexed: 12/13/2022] Open
Abstract
Importance Hip and knee arthroplasty are the most common inpatient surgical procedures for Medicare beneficiaries in the US, with substantial variation in cost and quality. Whether remote monitoring incorporating insights from behavioral science might help improve outcomes and increase value of care remains unknown. Objective To evaluate the effect of activity monitoring and bidirectional text messaging on the rate of discharge to home and clinical outcomes in patients receiving hip or knee arthroplasty. Design, Setting, and Participants Randomized clinical trial conducted between February 7, 2018, and April 15, 2019. The setting was 2 urban hospitals at an academic health system. Participants were patients aged 18 to 85 years scheduled to undergo hip or knee arthroplasty with a Risk Assessment and Prediction Tool score of 6 to 8. Interventions Eligible patients were randomized evenly to receive usual care (n = 153) or remote monitoring (n = 147). Those in the intervention arm who agreed received a wearable activity monitor to track step count, messaging about postoperative goals and milestones, pain score tracking, and connection to clinicians as needed. Patients assigned to receive monitoring were further randomized evenly to remote monitoring alone or remote monitoring with gamification and social support. Remote monitoring was offered before surgery, began at hospital discharge, and continued for 45 days postdischarge. Main Outcomes and Measures The primary outcome was discharge status (home vs skilled nursing facility or inpatient rehabilitation). Prespecified secondary outcomes included change in average daily step count and rehospitalizations. Results A total of 242 patients were analyzed (124 usual care, 118 intervention); median age was 66 years (interquartile range, 58-73 years); 78.1% were women, 45.5% were White, 43.4% were Black; and 81.4% in the intervention arm agreed to receive monitoring. There was no significant difference in the rate of discharge to home between the usual care arm (57.3%; 95% CI, 48.5%-65.9%) and the intervention arm (56.8%; 95% CI, 47.9%-65.7%) and no significant increase in step count in those receiving remote monitoring plus gamification and social support compared with remote monitoring alone. There was a statistically significant reduction in rehospitalization rate in the intervention arm (3.4%; 95% CI, 0.1%-6.7%) compared with the usual care arm (12.2%; 95% CI, 6.4%-18.0%) (P = .01). Conclusions and Relevance In this study, the remote monitoring program did not increase rate of discharge to home after hip or knee arthroplasty, and gamification and social support did not increase activity levels. There was a significant reduction in rehospitalizations among those receiving the intervention, which may have resulted from goal setting and connection to the care team. Trial Registration ClinicalTrials.gov Identifier: NCT03435549.
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Affiliation(s)
- Shivan J. Mehta
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - Eric Hume
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia
| | - Andrea B. Troxel
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Catherine Reitz
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - Laurie Norton
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Hannah Lacko
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia
| | - Caitlin McDonald
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - Jason Freeman
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Noora Marcus
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Kevin G. Volpp
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - David A. Asch
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Mittal S, Shukla AR, Sahadev R, Lee SY, Siu S, Gale EM, Plachter N, Srinivasan AK. Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative. J Pediatr Urol 2020; 16:846.e1-846.e7. [PMID: 33132029 DOI: 10.1016/j.jpurol.2020.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/10/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Opioid prescriptions have been implicated as one of the proximate causes of the national opioid epidemic. Children and adolescents and their families are at risk for increased opioid exposure through prescriptions after surgery. In pediatric urologic surgery, indications for postoperative opioids can vary widely and a focus on opioid stewardship is important to reduce potential harms. OBJECTIVE To measure the efficacy of a quality improvement initiative aimed to reduce post-operative opioids for pain management in a large pediatric surgical cohort. STUDY DESIGN Patients undergoing ambulatory pediatric urologic surgery at a tertiary children's hospital between July 2016 to June 2019 were analyzed. Structured physician peer-to-peer comparisons, electronic health record redesign and a standardized pain management protocol were implemented. Rate of opioid prescriptions per month, utilization of non-opioid analgesia, unplanned encounters in the emergency department and/or office during implementation were aggregated. Opioid doses and prescribed opioid days before and after protocol implementation were analyzed. A subcohort, from October-December 2018 was administered a patient-reported outcome questionnaire focused on pain management and return to baseline activity. RESULTS A total of 6684 consecutive outpatient urologic cases were included (median age = 3.3 years old (IQR 0.9-9.2) and 92.3% male). Comparing 6 months pre-intervention and the post-intervention latest 6 month intervals, opioid prescription rate decreased from 43.9% to 2.3% (p < 0.001). Additionally, non-opioid analgesia with ketorolac increased from 30.7% to 50.6% (p < 0.001). Concurrently, no differences in the rate of office visits within 5 days, overall ED visits, ED visits for pain or for bleeding within 30 days after implementation were identified. Between October to December 2018, 373 cases were performed and a Patient-Reported Outcome (PRO) questionnaire was completed for 128 of those patients (34%). Families reported a low patient pain score of 3.7 (SD 2.4) and a rapid postoperative recovery time of a median 2 (IQR 1-4) days to full resumption of pre-operative level of activity. High satisfaction with opioid reduction in post-operative pain management was reported (median score of 10 (IQR 8-10)). CONCLUSION Opioid prescriptions and utilization may be minimized without increasing unplanned encounters or adversely affecting quality of life. The QI framework utilized in this process can be implemented to reduce opioid exposure in other surgical patient populations.
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Affiliation(s)
- Sameer Mittal
- Children's Hospital of Philadelphia, Philadelphia PA, USA.
| | - Aseem R Shukla
- Children's Hospital of Philadelphia, Philadelphia PA, USA
| | | | - Seo Y Lee
- Children's Hospital of Philadelphia, Philadelphia PA, USA
| | - Sharmayne Siu
- Children's Hospital of Philadelphia, Philadelphia PA, USA
| | - Erica M Gale
- Children's Hospital of Philadelphia, Philadelphia PA, USA
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50
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MacKenna B, Bacon S, Walker AJ, Curtis HJ, Croker R, Goldacre B. Impact of Electronic Health Record Interface Design on Unsafe Prescribing of Ciclosporin, Tacrolimus, and Diltiazem: Cohort Study in English National Health Service Primary Care. J Med Internet Res 2020; 22:e17003. [PMID: 33064085 PMCID: PMC7600019 DOI: 10.2196/17003] [Citation(s) in RCA: 241] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/11/2020] [Accepted: 02/29/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In England, national safety guidance recommends that ciclosporin, tacrolimus, and diltiazem are prescribed by brand name due to their narrow therapeutic windows and, in the case of tacrolimus, to reduce the chance of organ transplantation rejection. Various small studies have shown that changes to electronic health record (EHR) system interfaces can affect prescribing choices. OBJECTIVE Our objectives were to assess variation by EHR systems in breach of safety guidance around prescribing of ciclosporin, tacrolimus, and diltiazem, and to conduct user-interface research into the causes of such breaches. METHODS We carried out a retrospective cohort study using prescribing data in English primary care. Participants were English general practices and their respective EHR systems. The main outcome measures were (1) the variation in ratio of safety breaches to adherent prescribing in all practices and (2) the description of observations of EHR system usage. RESULTS A total of 2,575,411 prescriptions were issued in 2018 for ciclosporin, tacrolimus, and diltiazem (over 60 mg); of these, 316,119 prescriptions breached NHS guidance (12.27%). Breaches were most common among users of the EMIS EHR system (breaches in 18.81% of ciclosporin and tacrolimus prescriptions and in 17.99% of diltiazem prescriptions), but breaches were observed in all EHR systems. CONCLUSIONS Design choices in EHR systems strongly influence safe prescribing of ciclosporin, tacrolimus, and diltiazem, and breaches are prevalent in general practices in England. We recommend that all EHR vendors review their systems to increase safe prescribing of these medicines in line with national guidance. Almost all clinical practice is now mediated through an EHR system; further quantitative research into the effect of EHR system design on clinical practice is long overdue.
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Affiliation(s)
- Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sebastian Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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