Development of a theory-based video-game intervention to increase advance care planning conversations by healthcare providers

Gamification in Critical Care Education and Practice

OBJECTIVES

To explore gamification as an alternative approach to healthcare education and its potential applications to critical care.

DATA SOURCES

English language manuscripts addressing: 1) gamification theory and application in healthcare and critical care and 2) implementation science focused on the knowledge-to-practice gap were identified in Medline and PubMed databases (inception to 2023).

STUDY SELECTION

Studies delineating gamification underpinnings, application in education or procedural mentoring, utilization for healthcare or critical care education and practice, and analyses of benefits or pitfalls in comparison to other educational or behavioral modification approaches.

DATA EXTRACTION

Data indicated the key gamification tenets and the venues within which they were used to enhance knowledge, support continuing medical education, teach procedural skills, enhance decision-making, or modify behavior.

DATA SYNTHESIS

Gamification engages learners in a visual and cognitive fashion using competitive approaches to enhance acquiring new knowledge or skills. While gamification may be used in a variety of settings, specific design elements may relate to the learning environment or learner styles. Additionally, solo and group gamification approaches demonstrate success and leverage adult learning theory elements in a low-stress and low-risk setting. The potential for gamification-driven behavioral modification to close the knowledge-to-practice gap and enable guideline and protocol compliance remains underutilized.

CONCLUSIONS

Gamification offers the potential to substantially enhance how critical care professionals acquire and then implement new knowledge in a fashion that is more engaging and rewarding than traditional approaches. Accordingly, educational undertakings from courses to offerings at medical professional meetings may benefit from being gamified.

Using a Video Game Intervention to Increase Hospitalists' Advance Care Planning Conversations with Older Adults: a Stepped Wedge Randomized Clinical Trial

BACKGROUND

Guidelines recommend Advance Care Planning (ACP) for seriously ill older adults to increase the patient-centeredness of end-of-life care. Few interventions target the inpatient setting.

OBJECTIVE

To test the effect of a novel physician-directed intervention on ACP conversations in the inpatient setting.

DESIGN

Stepped wedge cluster-randomized design with five 1-month steps (October 2020-February 2021), and 3-month extensions at each end.

SETTING

A total of 35/125 hospitals staffed by a nationwide physician practice with an existing quality improvement initiative to increase ACP (enhanced usual care).

PARTICIPANTS

Physicians employed for ≥ 6 months at these hospitals; patients aged ≥ 65 years they treated between July 2020-May 2021.

INTERVENTION

Greater than or equal to 2 h of exposure to a theory-based video game designed to increase autonomous motivation for ACP; enhanced usual care.

MAIN MEASURE

ACP billing (data abstractors blinded to intervention status).

RESULTS

A total of 163/319 (52%) invited, eligible hospitalists consented to participate, 161 (98%) responded, and 132 (81%) completed all tasks. Physicians' mean age was 40 (SD 7); most were male (76%), Asian (52%), and reported playing the game for ≥ 2 h (81%). These physicians treated 44,235 eligible patients over the entire study period. Most patients (57%) were ≥ 75; 15% had COVID. ACP billing decreased between the pre- and post-intervention periods (26% v. 21%). After adjustment, the homogeneous effect of the game on ACP billing was non-significant (OR 0.96; 95% CI 0.88-1.06; p = 0.42). There was effect modification by step (p < 0.001), with the game associated with increased billing in steps 1-3 (OR 1.03 [step 1]; OR 1.15 [step 2]; OR 1.13 [step 3]) and decreased billing in steps 4-5 (OR 0.66 [step 4]; OR 0.95 [step 5]).

CONCLUSIONS

When added to enhanced usual care, a novel video game intervention had no clear effect on ACP billing, but variation across steps of the trial raised concerns about confounding from secular trends (i.e., COVID).

TRIAL REGISTRATION

Clinicaltrials.gov; NCT04557930, 9/21/2020.