Implementation of behavioral economic approaches to improve evidence uptake for mechanically ventilated patients

实施行为经济学方法以提高机械通气患者的证据吸收

• 批准号: 10614507
• 负责人: Meeta Prasad Kerlin
• 金额: $ 67.52万
• 依托单位: UNIVERSITY OF PENNSYLVANIA
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-03-15 至 2025-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10614507
• 关键词: Accountability; Accounting; Acute Respiratory Distress Syndrome; Adherence; Affect; Air; American; Clinical; Cluster randomized trial; Cognitive; Communities; Data; Delirium; Diagnostic; Dose; Effectiveness; Electronic Health Record; Elements; Emotional; Environment; Evidence based practice; Guidelines; Health system; Heterogeneity; Hospital Mortality; Hybrids; Impairment; Inferior; Intensive Care Units; International; Intervention; Knowledge; Life; Literature; Lung; Mechanical ventilation; Methods; Monitor; Morbidity - disease rate; Organ failure; Outcome; Patient-Focused Outcomes; Patients; Physicians; Pneumonia; Population; Relaxation; Respiratory Failure; Sedation procedure; Sepsis; Survivors; Testing; Tidal Volume; Time; Trauma; Uncertainty; Ventilator; adverse outcome; arm; behavior change; behavior influence; behavioral economics; cluster randomized design; compare effectiveness; contextual factors; design; effectiveness outcome; future implementation; health care settings; implementation fidelity; implementation outcomes; implementation strategy; improved; improved outcome; innovation; lung injury; mortality; novel; patient population; patient subsets; pragmatic trial; pressure; randomized trial; respiratory; sedative; theories; treatment effect; uptake; ventilation

PROJECT SUMMARY By some estimates, up to one million Americans undergo invasive mechanical ventilation (MV) each year. MV can be life-saving, but can also be harmful by leading directly to lung injury by delivering artificially large breaths. A growing body of evidence has demonstrated that a specific strategy of “lung-protective ventilation” (LPV), which entails smaller breaths and reduced airway pressures, can reduce both short-term mortality and long-term morbidity. Among patients with acute respiratory distress syndrome (ARDS), a form of severe respiratory failure associated with common illnesses such as pneumonia, sepsis, and trauma, high-quality evidence has demonstrated that LPV reduces mortality, duration of mechanical ventilation, and long-term morbidity of patients with ARDS. Nonetheless, many patients with ARDS who undergo mechanical ventilation do not receive this life-saving therapy. Two reasons for this poor evidence uptake are lack of knowledge about LPV and uncertainty regarding who has ARDS at the time of MV initiation. However, recent recognition that LPV may improve outcomes even among patients without ARDS suggests that encouraging clinicians to begin with LPV for all patients may be an optimal strategy. Therefore, our main objective is to study simple strategies that may circumvent the barriers of knowledge and diagnostic uncertainty, to improve the utilization of LPV. We will conduct a large pragmatic trial of electronic health record (EHR)-based implementation strategies informed by behavioral economic principles to encourage LPV utilization among all MV patients. We will employ a Hybrid Trial Type 3 design to study implementation and effectiveness outcomes. We will test two hypotheses: (1) that a default order set (pre-populated with LPV settings) or an accountable justification prompt (requiring physicians to provide an explicit rationale when non-LPV settings are ordered) will increase LPV utilization among patients with and without ARDS, will be sustainable, and will improve overall clinical outcomes; and (2) that the addition of an accountable justification prompt requiring respiratory therapists to provide a rationale when non-LPV settings are documented will further improve outcomes. We will use a stepped-wedge, cluster randomized design across 12 ICUs. The specific aims of this trial are to: (1) compare fidelity to LPV with the implementation strategies; (2) evaluate the sustainability of the strategies and their effects; (3) explore whether clinician and environmental contextual factors modify the effect of the strategies; (4) compare the effectiveness of strategies to improve patient outcomes; (5) compare the specific efficacy of these strategies, accounting for imperfect adherence to LPV; and (6) evaluate how patient heterogeneity interacts with the strategies. This study will provide high-quality evidence regarding the ability of simple, readily scalable interventions to improve evidence-based practices among patients with very high morbidity and mortality, will expand the literature on effectiveness of LPV among broader patient populations, and will improve understanding of the utility of different behavioral economic strategies in settings in which treatment effects may be heterogeneous.

项目概要 据估计，每年有多达一百万美国人接受有创机械通气 (MV)。 可以挽救生命，但也可能有害，因为人为地输送大量物质，直接导致肺部损伤 越来越多的证据表明，“肺保护性通气”的具体策略。 （LPV）需要更小的呼吸和降低的气道压力，可以降低短期死亡率和 急性呼吸窘迫综合征（ARDS）患者的长期发病率，这是一种严重的疾病。 与肺炎、败血症和创伤等常见疾病相关的呼吸衰竭，高质量 有证据表明，LPV 可降低死亡率、机械通气持续时间和长期生存率。 尽管如此，许多 ARDS 患者接受机械通气。 没有接受这种挽救生命的治疗的原因有两个：缺乏相关知识。 LPV 和 MV 开始时谁患有 ARDS 的不确定性 然而，最近认识到这一点。 即使没有 ARDS 的患者，LPV 也可能改善预后，这表明鼓励支持者开始 对于所有患者来说，LPV 可能是一种最佳策略，因此，我们的主要目标是研究简单的策略。 这可能会规避知识障碍和诊断不确定性，从而提高 LPV 的利用率。 将针对基于电子健康记录（EHR）的实施策略进行大规模务实试验 我们将根据行为经济学原理鼓励所有 MV 患者使用 LPV。 混合试验类型 3 设计用于研究实施和有效性结果我们将测试两个假设： (1) 默认订单集（预先填充 LPV 设置）或负责任的理由提示（需要 医生在订购非 LPV 设置时提供明确的理由）将增加 LPV 利用率 在患有或不患有 ARDS 的患者中，这将是可持续的，并将改善总体临床结果；(2) 添加负责任的理由提示要求呼吸治疗师提供理由 当记录非 LPV 设置时，我们将使用阶梯楔形集群。 在 12 个 ICU 中进行随机设计，本试验的具体目的是：(1) 比较 LPV 与 LPV 的保真度。 实施策略； (2) 评估策略的可持续性及其效果； (3) 探讨是否 (4) 效果比较 改善患者治疗效果的策略；（5）比较这些策略的具体功效，并考虑到 LPV 依从性不理想；(6) 评估患者异质性与策略的相互作用。 研究将提供高质量的证据，证明简单、易于扩展的干预措施能够改善 在发病率和死亡率非常高的患者中进行循证实践，将扩大关于 LPV 在更广泛的患者群体中的有效性，并将提高对 LPV 效用的了解 在治疗效果可能不同的环境中采取不同的行为经济策略。

项目成果

Adherence to Lung Protective Ventilation in Patients With Coronavirus Disease 2019.

2019 年冠状病毒病患者坚持肺部保护性通气。

• 发表时间: 2021-08
• 作者: Levy, Elizabeth;Scott, Stefania;Tran, Teresa;Wang, Wei;Mikkelsen, Mark E;Fuchs, Barry D;Kerlin, Meeta Prasad
• 通讯作者: Kerlin, Meeta Prasad

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.

实施推动以促进低潮气量通气 (INPUT) 的利用：一项阶梯式楔形混合 III 型试验，旨在改进循证机械通气管理策略。

• 发表时间: 2021
• 作者: Kerlin, Meeta Prasad;Small, Dylan;Fuchs, Barry D;Mikkelsen, Mark E;Wang, Wei;Tran, Teresa;Scott, Stefania;Belk, Aerielle;Silvestri, Jasmine A;Klaiman, Tamar;Halpern, Scott D;Beidas, Rinad S
• 通讯作者: Beidas, Rinad S