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: 10442225
• 负责人: Katherine Rinaldi Courtright
• 金额: $ 66.39万
• 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/10442225
• 关键词: Address; Adopted; Affect; Age; 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; Face; Family; Future; Goals; Guidelines; Health system; Heterogeneity; Hospitals; Hybrids; Inpatients; Intervention; Intervention Studies; Interview; Knowledge; Malignant Neoplasms; Methods; Modeling; Palliative Care; Patient Care; Patient Outcomes Assessments; Patient-Focused Outcomes; Patients; Pilot Projects; Process; Prognosis; Quality of life; Race; Randomized; Resources; Sampling; Science; Services; Specialist; Specific qualifier value; Subgroup; Symptoms; Testing; United States National Institutes of Health; base; behavior change; care delivery; care seeking; care systems; cohort; contextual factors; cost; design; deviant; economic outcome; effectiveness evaluation; effectiveness testing; experience; high risk; 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; preference; primary outcome; prognostic; programs; provider behavior; psychologic; randomized trial; response; secondary outcome; symptom treatment; therapy development; tool; 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.

项目总结 数百万患有严重疾病的美国人会经历沉重的症状，并受到攻击性的攻击 与他们的目标和喜好不一致的护理。越来越多的证据表明，姑息疗法 护理需要一种支持性的护理方法，专注于最大限度地提高生活质量，改善患者- 以临床和经济成果为中心。出于这个原因，国家指南建议临床医生 要么自己提供姑息治疗(主要)，要么咨询专家(专家)作为标准严重护理的一部分 疾病护理。出于这些原因，美国的大多数医院都投资于专科姑息治疗项目。 然而，对于患有严重疾病的患者，尤其是那些患有 晚期阿尔茨海默病和相关痴呆症(ADRD)以及专家姑息治疗服务的使用 通常是低效和不公平的，主要是由于临床医生很难识别哪些患者最有可能 从他们身上获益。许多医院已经开始在电子健康记录中实施预后触发 (电子病历)，以促进更可靠和公平的患者识别，然而，没有一个经过严格的测试 他们对以患者为中心的结果的影响。此外，姑息治疗的触发因素不能仅仅依赖于 姑息治疗专家的劳动力有限，但更多的是促进初级和专科的方法 姑息治疗是必要的，但缺乏如何以最佳方式做到这一点的证据。这项研究的主要目的 评估一种策略，该策略将基于EHR的预后触发与两个有效的临床医生指导相结合 推动为住院的重病患者提供初级或专科姑息治疗。具体来说， 行为干预包括向初级临床医生发出简单的EHR警报，以照顾已确定的患者 这需要他们积极选择是否提供初级姑息治疗，而且只有在他们拒绝的情况下， 专家姑息治疗的默认顺序是输入的，他们可以选择退出。我们将进行一次混合动力 类型1务实的整群随机试验，对6家不同医院的近7,000名患者进行研究 干预措施对无住院日和许多其他以患者为中心的、临床和经济的有效 结果。我们还将进行嵌入式混合方法研究，以了解临床医生和医院 影响干预的背景因素。最后，我们将评估治疗效果。 ADRD患者和其他预先指定的亚组之间的异质性以确定哪些类型的 患者从推动姑息治疗的系统方法中受益最大。这项研究将提供 关于可扩展和可持续的方法的有效性的高质量证据 在一个庞大和多样化的患者队列中进行初级和专科姑息治疗，将促进 姑息治疗的诱因科学将为最有可能受益的患者类型提供新的见解 从系统识别姑息治疗，并将创造关于如何建立医院的新知识 有利于期望的临床医生行为改变的环境，以改善大病护理。