nudging intensivists: simple interventions to change end ... · nudging intensivists: simple...
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Scott D. Halpern, M.D., Ph.D.Associate Professor of Medicine, Epidemiology, and Medical Ethics & Health Policy
Director, Fostering Improvement in End-of-Life Decision Science (FIELDS) program
Deputy Director, Center for Health Incentives and Behavioral Economics (CHIBE)
Nudging intensivists: Simple interventions to change end-of-life care
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Grant support
NIH (NHLBI, NIA, NCI)
Robert Wood Johnson Foundation
American Heart Association
Greenwall Foundation
Otto Haas Charitable Trust
Gordon and Betty Moore Foundation
Donaghue Foundation Paid consultancyABIM Foundation’s Choosing Wisingprogram
In-kind research support
• Cerner
• CVS Health
• Ascension Health
• Kaiser Permanente
• Carolinas HealthCare System
Disclosures
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Hart JL, et al. JAMA Intern Med 2015
Highly variable treatment intensity across ICUs
13,405 patients with pre-existing limitations on life support admitted to 141 ICUs in 105
U.S. hospitals
among-ICU median
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And among physicians within the same ICU…
9 intensivists caring for 1,363 ICU patients admitted to Case Western from 2002-2005
Garland A, Connors AF. J Pall Med 2007; 10: 1298
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And even within physician, depending on how strained the ICU is!
Hua, M et al. Intensive Care Medicine 2016
10,000 patients dying in 161 U.S. ICUs 2001-2008
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Anesi GL, Halpern SD. Intensive Care Med 2016
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Can we leverage electronic health records to reduce undue variability / improve EOL care?
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Inpatient palliative care: Not enough of a good thing?
• 70-80% hospitals >50 beds have inpatient palliative care service (IPCS)
• Observational evidence suggests effectiveness and cost reduction
• In non-cancer populations, <10% of ‘eligible’ patients seen
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Courtright K, et al. Annals ATS 2016
How heavy-handed ought we be?
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0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Automatic triggers for Palliative Care consultation
Family meetings
Withdrawal of life support
Early mobilization and/or physical therapy
Regular ICU delirium assessment
Mechanical ventilation liberation
Sedation management for mechanically ventilatedpatients
Clinical protocols in Pennsylvania ICUs
Kohn R, et al. (under review)
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Comparison: palliative care consultation at MD discretion (usual care) vs. EHR-ordered palliative care consultation on 3rd
hospital day (MD can opt out)
Sample: ~18,000 patients at 11 Ascension Health hospitals with integrated EHR
Primary outcome: composite of hospital LOS and mortality
Secondary outcomes: documentation of goals of care, family meetings, pain/dyspnea/GI assessments; readmissions; costs; other
REDAPS: Randomized Evaluation of Default Access to Palliative Services
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Default Palliative Care Standing Order
Hospitalization
day 0 = admission
day 1 nursing documentation& review of history elements
day 1 study criteria met; system
creates palliativecare consult order with start time of
day 2 at 15:00
day 2, 15:00palliative care consult is activated
24-hour opt-out alert intervalE H R notification to physicians
for opportunity to cancel automated palliative care consult order
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Notification of Consult Order
Appears on Day 1 after 1500 to clinicians responsible for patients’ care.
Alerts one time per clinician when chart is opened until Day 2 1500
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Cancelling the default order
Right click Consult PC Order and select Cancel/DC
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Must provide reason to cancel order
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Select one reason or enter free text in “Other Reason”
Click on green check mark to SIGN.
Must provide reason to cancel order
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Must provide reason to cancel order
OK button is dithered
User must select Document
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• 1,993 students at:
• Both groups predicted that a given student would be happier at a California school
• But no differences in groups’ self-reported happiness
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Turnbull A, et al. Crit Care Med 2014
Can we use docs’ tunnel vision to improve care?
630 U.S. intensivistsindicated whether they would discuss withdrawal of life
support with families
Arms:1. Intensivist has to
document prognosis
2. Patient wants life support regardless
3. Patient doesn’t want life support if bad prognosis
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Meeker D, et al. JAMA 2016
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Accountable Justification
Meeker D, et al. JAMA 2016
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Carolinas HealthCare System
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FIELDS Team
Dominique Bayard, MD Vanessa Madden, BSc Brian Bayes, MS
David Casarett, MD Andrea Troxel, ScD George Anesi, MD, MA
Elizabeth Cooney, MPH Mark Mikkelsen, MD, MS Rachel Kohn, MD
Kate Courtright, MD, MS Michael Olorunnisola Meeta Kerlin, MD, MS
Michael Detsky, MD, MS Emily Rubin, MD, JD Kendra Moore
Mary Ersek, RN, PhD Sarah Ratcliffe, PhD Alexis Zebrowski
Sarah Grundy Dylan Small, PhD
Michael Josephs Stephanie Szymanski
Nicole Gabler, PhD Kevin Volpp, MD, PhD
Michael Harhay, PhD (c) Jackie McMahon, MSW
Joanna Hart, MD, MS Kuldeep Yadav
Emma Levine, PhD (c) Anna Buehler
Lucy Chen Gary Weissman, MD
chibe.upenn.edu/fields-program