Leveraging the electronic health record and behavioral nudges to promote primary and specialist palliative care for inpatients with serious illness: A pragmatic trial

利用电子健康记录和行为推动促进对重症住院患者的初级和专科姑息治疗：一项务实试验

• 批准号: 10624326
• 负责人: Katherine Rinaldi Courtright
• 金额: $ 65.98万
• 依托单位: UNIVERSITY OF PENNSYLVANIA
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-06-01 至 2027-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10624326
• 关键词: Address; Adopted; Affect; Age; Alzheimer' s disease patient; Alzheimer' s disease related dementia; American; Behavior Therapy; Behavioral; Caring; Cessation of life; Characteristics; Clinical; Cluster randomized trial; Communication; Consolidated Framework for Implementation Research; Consult; Consultations; Data; Decision Making; Diagnosis; Documentation; Effectiveness; Effectiveness of Interventions; Electronic Health Record; Environment; Equity; Face; Family; Future; Goals; Guidelines; Health system; Heterogeneity; Hospitalization; Hospitals; Hybrids; Inequity; Inpatients; Intervention; Intervention Studies; Interview; Investments; Knowledge; Malignant Neoplasms; Methods; Modeling; Palliative Care; Patient Outcomes Assessments; Patient-Focused Outcomes; Patients; Pilot Projects; Process; Prognosis; Quality of life; Race; Randomized; Recommendation; Resources; Sampling; Science; Services; Specialist; Specific qualifier value; Subgroup; Symptoms; Testing; United States National Institutes of Health; behavior change; care delivery; care seeking; care systems; clinical predictors; cohort; contextual factors; cost; design; economic outcome; effectiveness evaluation; effectiveness testing; experience; high risk; hospital care; implementation framework; implementation strategy; improved; innovation; inpatient service; insight; intervention delivery; medical specialties; mortality; mortality risk; multiple chronic conditions; novel; patient oriented; patient subsets; pragmatic trial; predictive modeling; predictive tools; preference; primary care clinician; primary outcome; prognostic; programs; provider behavior; psychologic; randomized trial; response; secondary outcome; symptom treatment; therapy development; treatment effect; uptake

PROJECT SUMMARY Millions of Americans living with serious illness experience burdensome symptoms and receive aggressive care that is not aligned with their goals and preferences. A growing body of evidence suggests that palliative care, which entails a supportive approach to care focused on maximizing quality of life, improves patient- centered, clinical, and economic outcomes. For this reason, national guidelines recommend that clinicians either provide palliative care themselves (primary) or consult experts (specialist) as part of standard serious illness care. For these reasons, most hospitals in the U.S. have invested in specialist palliative care programs. Yet, palliative care delivery remains insufficient among patients with serious illness, particularly those with advanced Alzheimer's Disease and Related Dementias (ADRD), and use of specialist palliative care services is often inefficient and inequitable, largely due to clinicians' difficulty identifying which patients are most likely to benefit from them. Many hospitals have begun to implement prognostic triggers in the electronic health record (EHR) to facilitate more reliable and equitable patient identification, however, none have been rigorously tested for their effects on patient-centered outcomes. Furthermore, palliative care triggers cannot solely rely on the limited workforce of palliative care specialists, but rather approaches that promote primary and specialist palliative care are needed, yet evidence is lacking for how to optimally do so. The main objective of this study is to evaluate a strategy that combines an EHR-based prognostic-trigger with two effective clinician-directed nudges to provide either primary or specialist palliative care for seriously ill hospitalized patients. Specifically, the behavioral intervention involves a simple EHR alert to the primary clinicians caring for identified patients that requires them to actively choose whether or not to provide primary palliative care, and only if they decline, a default order for specialist palliative care is entered from which they can opt-out. We will conduct a hybrid type 1 pragmatic, cluster randomized trial among nearly 7,000 patients across 6 diverse hospitals to study the intervention's effectiveness on hospital-free days and numerous other patient-centered, clinical, and economic outcomes. We will also conduct an embedded mixed methods study to understand clinician and hospital contextual factors that influence the intervention's uptake. Finally, we will evaluate for treatment effect heterogeneity among patients with ADRD and other pre-specified subgroups to determine which types of patients derive the greatest benefit from a systematic approach to nudge palliative care. This study will provide high-quality evidence regarding the effectiveness of a scalable and sustainable approach to promote collaborative primary and specialist palliative care among a large and diverse patient cohort, will advance the science of triggers for palliative care, will provide new insights into the types of patients most likely to benefit from systematic identification for palliative care, and will create new knowledge about how to establish hospital environments conducive to desired clinician behavior change to improve serious illness care.

项目摘要 数以百万计的患有严重疾病的美国人经历繁重的症状并受到侵略性 与他们的目标和偏好不符的关心。越来越多的证据表明姑息 护理需要一种支持性的护理方法，重点是最大化生活质量，可以改善患者 - 集中，临床和经济成果。因此，国家准则建议临床医生 作为标准严重的一部分，请自己提供姑息治疗（主要）或咨询专家（专家） 疾病护理。由于这些原因，美国大多数医院都投资了专业的姑息治疗计划。 然而，在患有严重疾病的患者中，姑息治疗的分娩仍然不足，特别是 高级阿尔茨海默氏病和相关痴呆症（ADRD），并使用专业姑息治疗服务 通常效率低下且不公平，这主要是由于临床医生难以确定哪些患者最有可能 从他们那里受益。许多医院已经开始在电子健康记录中实施预后触发器 （EHR）为了促进更可靠，更公平的患者识别，但没有进行严格测试 因为它们对以患者为中心的结果的影响。此外，姑息治疗触发者不能仅依靠 姑息治疗专家的劳动力有限，而是促进初级和专家的方法 需要姑息治疗，但缺乏证据表明如何进行最佳选择。这项研究的主要目标 是评估一种将基于EHR的预后触发与两个有效临床医生定向的策略相结合的策略 轻推以为严重住院的患者提供初级或专业的姑息治疗。具体来说， 行为干预涉及对照顾已确定患者的主要临床医生的简单EHR警报 这要求他们积极选择是否提供主要的姑息治疗，并且只有当他们下降时， 输入了可以选择退出的专业姑息治疗的默认订单。我们将进行混合动力 在6家不同医院的近7,000名患者中，1型务实的簇，聚类随机试验，研究 干预对无医院日期的有效性以及许多其他以患者为中心的，临床和经济的有效性 结果。我们还将进行一项嵌入式混合方法研究，以了解临床医生和医院 影响干预措施的上下文因素。最后，我们将评估治疗效果 ADRD患者和其他预先指定亚组的异质性，以确定哪种类型 患者从系统的推动姑息治疗方法中获得了最大的好处。这项研究将提供 有关可扩展和可持续方法促进的有效性的高质量证据 在大型且多样化的患者队列中的协作初级和专业姑息治疗将促进 姑息治疗的触发器科学将为最有可能受益的患者类型提供新的见解 从姑息治疗的系统识别，并将创建有关如何建立医院的新知识 环境有利于所需的临床医生行为改变以改善严重的疾病护理。