Impact of Behavioral Nudges on the Quality of Serious Illness Conversations Among Patients With Cancer: Secondary Analysis of a Randomized Controlled Trial

Abstract

PURPOSE: Serious Illness Conversations (SICs) are structured conversations between clinicians and patients about prognosis, treatment goals, and end-of-life preferences. Although behavioral interventions may prompt earlier or more frequent SICs, their impact on the quality of SICs is unclear. METHODS: This was a secondary analysis of a randomized clinical trial ( NCT03984773 ) among 78 clinicians and 14,607 patients with cancer testing the impact of an automated mortality prediction with behavioral nudges to clinicians to prompt more SICs. We analyzed 318 randomly selected SICs matched 1:1 by clinicians (159 control and 159 intervention) to compare the quality of intervention vs. control conversations using a validated codebook. Comprehensiveness of SIC documentation was used as a measure of quality, with higher integer numbers of documented conversation domains corresponding to higher quality conversations. A conversation was classified as high-quality if its score was ≥ 8 of a maximum of 10. Using a noninferiority design, mixed effects regression models with clinician-level random effects were used to assess SIC quality in intervention vs. control groups, concluding noninferiority if the adjusted odds ratio (aOR) was not significantly < 0.9. RESULTS: Baseline characteristics of the control and intervention groups were similar. Intervention SICs were noninferior to control conversations (aOR 0.99; 95% CI, 0.91 to 1.09). The intervention increased the likelihood of addressing patient-clinician relationship (aOR = 1.99; 95% CI, 1.23 to 3.27; P < .01) and decreased the likelihood of addressing family involvement (aOR = 0.56; 95% CI, 0.34 to 0.90; P < .05). CONCLUSION: A behavioral intervention that increased SIC frequency did not decrease their quality. Behavioral prompts may increase SIC frequency without sacrificing quality.

The association between telemedicine, advance care planning, and unplanned hospitalizations among high‐risk patients with cancer

“…38,39 As such, it is a reliable proxy for advance care planning and has been successfully used in prior studies with the University of Pennsylvania EHR. 36,37,40 Unplanned hospitalizations were identified from inpatient encounters within the University of Pennsylvania system identified in the EHR; planned hospitalizations, such as scheduled inpatient chemotherapy, were excluded.…”

“…These were coded as present or absent on the basis of a validated codebook used in a previous qualitative study of SICs 45 as well as to assess advance care planning within the University of Pennsylvania health system. 40 High-quality advance care planning was defined as including prognosis communication, patient prognostic understanding, and either patient goals or their fears and worries. These were based on recommendations for quality assessment of serious illness communication from national experts.…”

“…Documentation of advance care planning in the EHR is a guideline‐based quality standard and the primary mechanism by which goals of care communication get translated into practice 38,39 . As such, it is a reliable proxy for advance care planning and has been successfully used in prior studies with the University of Pennsylvania EHR 36,37,40 . Unplanned hospitalizations were identified from inpatient encounters within the University of Pennsylvania system identified in the EHR; planned hospitalizations, such as scheduled inpatient chemotherapy, were excluded.…”

“…The nine features from the SIC note template include the (1) prognosis communication, (2) prognostic understanding, (3) information preferences, (4) goals, (5) fears and worries, (6) strengths, (7) critical abilities, (8) tradeoffs, and (9) family involvement. These were coded as present or absent on the basis of a validated codebook used in a previous qualitative study of SICs 45 as well as to assess advance care planning within the University of Pennsylvania health system 40 . High‐quality advance care planning was defined as including prognosis communication, patient prognostic understanding, and either patient goals or their fears and worries.…”

Interventions aiming to improve advance care planning uptake in oncology: a scoping review of recent randomized controlled trials

“…The cancer care contexts, intervention modalities, and main outcomes were heterogeneous. The interventions were primarily multimodal and of three main types: those that aimed to improve ACP uptake via patient/caregiver-oriented tools (three RCTs) [12–16], those involving trained ACP facilitators’ support of patients and caregivers [six RCTs, including one targeting adolescent and young-adult (AYA) patients] [17,18 ▪ ,19–37], and one involving the prompting of trained physicians’ implementation of ACP discussions in practice (one RCT) [38,39 ▪ ,40–42]. Patient, caregiver, HCP, and healthcare service outcomes were measured.…”