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

项目总结 据估计，每年有多达100万美国人接受有创机械通气(MV)。中压 可以是救命的，但也可能是有害的，因为它直接导致肺损伤，因为人工合成的 呼吸。越来越多的证据表明，有一种特殊的“肺保护性通风”策略 (LPV)需要更小的呼吸和更低的呼吸道压力，可以降低短期死亡率和 长期发病率。在急性呼吸窘迫综合征(ARDS)患者中，一种严重的 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、机械通气时间和长期存活时间。 ARDS患者的发病率。尽管如此，许多接受机械通气的ARDS患者 不要接受这种救命疗法。证据采集力不佳的两个原因是缺乏对 LPV和关于在MV开始时谁患有ARDS的不确定性。然而，最近认识到 LPV可能会改善预后，即使在没有ARDS的患者中也表明鼓励临床医生开始 对于所有患者，LPV可能是一种最佳的治疗策略。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，提高LPV的利用率。我们 将进行基于电子健康记录(EHR)的大型务实试验，并告知实施策略 按照行为经济学原则，鼓励所有MV患者使用LPV。我们将聘请一名 研究实施和有效性结果的混合试验类型3设计。我们将检验两个假设： (1)默认订单设置(预填入LPV设置)或责任调整提示(需要 医生在订购非LPV设置时提供明确的理由)将提高LPV利用率 在患有和不患有ARDS的患者中，这将是可持续的，并将改善总体临床结果；以及(2) 增加一个负责任的理由促使呼吸治疗师提供一个理由 当记录非LPV设置时，将进一步改善结果。我们将使用阶梯形楔子，集群 12个ICU的随机设计。本试验的具体目的是：(1)比较LPV与LPV的保真度 实施战略；(2)评估战略的可持续性及其效果；(3)探讨 临床医生和环境背景因素改变策略的效果；(4)比较策略的有效性 改善患者预后的策略；(5)比较这些策略的具体疗效，说明 不完全坚持LPV；以及(6)评估患者的异质性如何与策略相互作用。这 研究将提供关于简单、容易扩展的干预措施的能力的高质量证据 在发病率和死亡率非常高的患者中进行循证实践，将扩大关于以下方面的文献 LPV在更广泛的患者群体中的有效性，并将提高对LPV的效用的理解 在治疗效果可能不同的情况下，不同的行为经济策略。

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.