Behavioral economic implementation strategies to improve serious illness communication between clinicians and high-risk patients with cancer: protocol for a cluster randomized pragmatic trial

Abstract

Background Serious illness conversations (SICs) are an evidence-based approach to eliciting patients’ values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics (“nudges”) that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion—either alone or in combination with clinician nudges that additionally compare performance relative to peers—may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. Methods We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. Discussion This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. Trial registration ClinicalTrials.gov, NCT04867850. Registered on April 30, 2021. Funding National Cancer Institute P50CA244690

Oncologist Peer Comparisons as a Behavioral Science Strategy to Improve Hospice Utilization

“…Encouraging upstream serious illness conversation and PC referral is important, and behavioral economic implementation strategies are ongoing. 46…”

“…Encouraging upstream serious illness conversation and PC referral is important, and behavioral economic implementation strategies are ongoing. 46 Behavioral science would be best aligned with sensible incentives to oncology providers and health systems aimed at meeting widely agreed upon standards. In the area of quality EOL care, they should consider outcomes important Guide choice through default options Automatically set up appointments for hospice information visits at predefined set points unless oncologist opts out Enable choice Increase options for hospice access through innovation in access (concurrent cancer-directed therapy with hospice)…”

Precision Palliative Care as a Pragmatic Solution for a Care Delivery Problem

“…6,43 Successful work in behavioral science has already incentivized earlier referral to specialty PC, 11 hospice use, 41 and better conversations for seriously ill patients. 29,30,44…”

“…6,43 Successful work in behavioral science has already incentivized earlier referral to specialty PC, 11 hospice use, 41 and better conversations for seriously ill patients. 29,30,44 In conclusion, specialty PC has a major role in cancer care delivery, although it must be deployed in a staged and sustainable fashion, targeted to individual and caregiver needs. As it now stands, current clinical guidelines for specialty PC referral apply a one-size-fits-all framework to often nuanced levels of PC need.…”

Is Improving the Penetration Rate of Palliative Care the Right Measure?

“…30 Development, dissemination, and implementation strategies are needed to improve palliative care penetration and uptake, while ensuring that the composition of clinical care teams, the domains of our interventions, and the outcomes of patients and caregivers reflect the data from clinical trials. 31 Ongoing work in behavioral economics and implementation science promoting both primary and specialty palliative care is encouraging, [32][33][34][35] but more attention is needed to address the well-described disparities in the receipt of palliative care services. 36 In our medical journals, we will continue to see and hear that palliative care is good medicine.…”