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: 9888214
• 负责人: Meeta Prasad Kerlin
• 金额: $ 77.74万
• 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 2024-02-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9888214
• 关键词: Accounting; Adherence; Adult Respiratory Distress Syndrome; Affect; Air; American; Clinical; Cluster randomized trial; Cognitive; Communities; Data; Delirium; Diagnostic; Dose; Effectiveness; Electronic Health Record; Elements; Emotional; Environment; Evidence based practice; Future; Guidelines; Health system; Heterogeneity; Hospital Mortality; Hybrids; Impairment; Inferior; Intensive Care Units; International; Intervention; Knowledge; Life; Literature; Lung; Mechanical ventilation; Mechanics; Methods; Monitor; Morbidity - disease rate; Organ failure; Outcome; Patient-Focused Outcomes; Patients; Physicians; Pneumonia; Population; Randomized; Respiratory Failure; Savings; Sedation procedure; Sepsis; Survivors; Testing; Tidal Volume; Time; Trauma; Uncertainty; Ventilator; adverse outcome; arm; base; behavior change; behavior influence; behavioral economics; compare effectiveness; contextual factors; design; health care settings; implementation strategy; improved; improved outcome; innovation; lung injury; mortality; novel; patient population; patient subsets; pragmatic trial; pressure; primary outcome; randomized trial; respiratory; secondary outcome; 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.

项目摘要 据估计，每年有多达100万美国人接受有创机械通气（MV）。MV 可以挽救生命，但也可能是有害的，因为通过人为地输送大量的 呼吸越来越多的证据表明，一种特殊的“肺保护性通气”策略 (LPV)，这需要更少的呼吸和降低气道压力，可以降低短期死亡率， 长期发病率。在急性呼吸窘迫综合征（ARDS）患者中， 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 ARDS患者的发病率。尽管如此，许多接受机械通气的ARDS患者 不要接受这种拯救生命的治疗。证据吸收不足的两个原因是缺乏对以下方面的了解： LPV和关于MV开始时谁患有ARDS的不确定性。然而，最近认识到， LPV甚至可以改善无ARDS患者的预后，这表明鼓励临床医生开始 对所有患者进行LPV可能是最佳策略。因此，我们的主要目标是研究简单的策略 这可能会绕过知识和诊断不确定性的障碍，以提高LPV的利用率。我们 将进行一个大型的电子健康记录（EHR）为基础的实施战略的实用性试验， 通过行为经济学原则，鼓励所有MV患者使用LPV。我们将雇用一名 混合试验3型设计旨在研究实施和有效性结局。我们将测试两个假设： (1)默认订单设置（预先填充LPV设置）或可解释的理由提示（需要 当订购非LPV设置时，医生应提供明确的理由）将增加LPV利用率 在有和没有ARDS的患者中，将是可持续的，并将改善整体临床结局;和（2） 增加一个负责任的理由提示，要求呼吸治疗师提供理由， 当记录非LPV设置时，将进一步改善结局。我们将使用一个阶梯楔，集群 12个ICU的随机设计。本试验的具体目的是：（1）比较LPV的保真度与 （2）评估战略的可持续性及其效果;（3）探讨是否 临床医生和环境背景因素会影响策略的效果;（4）比较策略的有效性 改善患者结局的策略;（5）比较这些策略的具体疗效， 对LPV的不完全依从性;（6）评估患者异质性如何与策略相互作用。这 这项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，将扩大以下文献： LPV在更广泛的患者人群中的有效性，并将提高对LPV效用的理解。 不同的行为经济学策略，在设置中，治疗效果可能是异质性的。