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

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Samuel U. Takvorian ◽  
Justin Bekelman ◽  
Rinad S. Beidas ◽  
Robert Schnoll ◽  
Alicia B. W. Clifton ◽  
...  
Keyword(s):  
High Risk ◽  
Contextual Factors ◽  
Pragmatic Trial ◽  
Implementation Strategies ◽  
Structured Interviews ◽  
Serious Illness ◽  
High Risk Patients ◽  
Patients With Cancer ◽  
Risk Patients ◽  
Cluster Randomized

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

scholarly journals Behavioral Economic Implementation Strategies to Improve Serious Illness Communication Between Clinicians and High-risk Patients With Cancer: Protocol for a Cluster Randomized Pragmatic Trial

2021 ◽  
Author(s):  
Samuel U. Takvorian ◽  
Justin Bekelman ◽  
Rinad S. Beidas ◽  
Robert Schnoll ◽  
Alicia B.W. Clifton ◽  
...  
Keyword(s):  
High Risk ◽  
Contextual Factors ◽  
Pragmatic Trial ◽  
Implementation Strategies ◽  
Structured Interviews ◽  
Serious Illness ◽  
High Risk Patients ◽  
Patients With Cancer ◽  
Risk Patients ◽  
Cluster Randomized

Abstract BackgroundSerious 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. MethodsWe will conduct a 2x2 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 5,500 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 effectiveness of nudges with an eye towards health equity.DiscussionThis 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 registrationClinicaltrials.gov, NCT04867850. Registered April 30, 2021. https://clinicaltrials.gov/ct2/show/NCT04867850?term=serious+illness&draw=2&rank=3

scholarly journals Putting veterans with heart failure FIRST improves follow-up and reduces readmissions

2019 ◽  
Vol 8 (1) ◽  
pp. e000386 ◽  
Author(s):  
Serena Michelle Ogunwole ◽  
Jason Phillips ◽  
Amber Gossett ◽  
John Richard Downs
Keyword(s):  
Heart Failure ◽  
High Risk ◽  
Best Practices ◽  
Implementation Strategies ◽  
Quality Improvement Initiative ◽  
Medicine Department ◽  
High Risk Patients ◽  
Resource Limited ◽  
Risk Patients

BackgroundDespite improvements in length of stay and mortality, congestive heart failure (CHF) remains the most common cause of 30-day readmissions to the hospital. Though multiple studies have found that early follow-up after discharge (eg, within 7 days) is critical to improving 30-day readmissions, implementation strategies are challenging in resource-limited settings. Here we present a quality improvement initiative aimed at improving early follow-up while maximising available resources.MethodsThis was a medical resident-driven initiative. A process map of the discharge and follow-up appointment process was created that identified multiple areas for improvement. Based on these findings, a two-part intervention was implemented. First, heart failure discharge education with focus on early follow-up was disseminated to providers throughout the internal medicine department. Subsequently, improved identification of high-risk patients (Failure Intervention Risk StratificationTool) and innovative use of the existing electronic medical record (EMR) were employed to sustain and improve on gains from the first set of interventions.ResultsWe increased our 7-day follow-up rate from 47% to 57% (p=0.429) and decreased the average time to follow-up from 17.6 days to 8.7 days (p=0.016) following the first intervention. The percentage of patients readmitted within 30 days after discharge at baseline (2012–2013) and following the first intervention (education and standardisation of follow-up scheduling) and second intervention (risk stratification, intensive follow-up and EMR change) was 25% and 21%, respectively. Thirty-day mortality rate decreased from 10% in 2011 to 7.16% in December 2015.ConclusionClose hospital discharge follow-up and identification of high-risk patients with CHF are useful approaches to reduce readmissions. Using the existing EMR tool for identifying high-risk patients and improving adherence to best practices is an effective intervention. In patients with CHF these strategies improved time to follow-up and 30-day readmissions while decreasing mortality.

scholarly journals Systematic depression screening in high-risk patients attending primary care: a pragmatic cluster-randomized trial

2013 ◽  
Vol 13 (1) ◽  
Author(s):  
Irene Romera ◽  
Ángel L Montejo ◽  
Enric Aragonés ◽  
José Ángel Arbesú ◽  
Celso Iglesias-García ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Randomized Trial ◽  
Cluster Randomized Trial ◽  
Depression Screening ◽  
High Risk Patients ◽  
Risk Patients ◽  
Cluster Randomized

Prevention of Xerostomia-Related Dental Caries in Irradiated Cancer Patients

1977 ◽  
Vol 56 (2) ◽  
pp. 99-104 ◽  
Author(s):  
Samuel Dreizen ◽  
Lee R. Brown ◽  
Thomas E. Daly ◽  
Joe B. Drane
Keyword(s):  
High Risk ◽  
Dental Caries ◽  
Cancer Patients ◽  
Oral Hygiene ◽  
High Risk Patients ◽  
Patients With Cancer ◽  
Risk Patients ◽  
Topical Fluoride

Three caries preventative regimens: oral hygiene ; oral hygiene and topical fluoride; and oral hygiene, topical fluoride, and sucrose restriction were evaluated in patients with cancer given xerostomia-producing radiotherapy. The oral hygiene-fluoride gel combination was remarkably effective in protecting these high risk patients from caries, regardless of the cariogenicity of the diet.

scholarly journals Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Brian P. Jenssen ◽  
Robert Schnoll ◽  
Rinad Beidas ◽  
Justin Bekelman ◽  
Anna-Marika Bauer ◽  
...  
Keyword(s):  
Tobacco Use ◽  
Cancer Care ◽  
Contextual Factors ◽  
Treatment Engagement ◽  
Implementation Strategies ◽  
Secondary Outcome ◽  
Evidence Based ◽  
Structured Interviews ◽  
Behavioral Economic ◽  
Cluster Randomized

Abstract Background Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. Methods A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or “nudges”) promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. Discussion This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. Trial registration Clinicaltrials.gov, NCT04737031. Registered 3 February 2021.

scholarly journals LO06: Development of practice recommendations for ED management of syncope by mixed methods

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S8-S9
Author(s):  
V. Thiruganasambandamoorthy ◽  
M. Taljaard ◽  
N. Hudek ◽  
J. Brehaut ◽  
B. Ghaedi ◽  
...  
Keyword(s):  
High Risk ◽  
Low Risk ◽  
Cardiac Monitoring ◽  
Structured Interviews ◽  
High Risk Patients ◽  
Practice Recommendations ◽  
Medium Risk ◽  
Risk Patients ◽  
Risk Categories

Introduction: Emergency department (ED) syncope management is extremely variable. We developed practice recommendations based on the validated Canadian Syncope Risk Score (CSRS) and outpatient cardiac monitoring strategy with physician input. Methods: We used a 2-step approach. Step-1: We pooled data from the derivation and validation prospective cohort studies (with adequate sample size) conducted at 11 Canadian sites (Sep 2010 to Apr 2018). Adults with syncope were enrolled excluding those with serious outcome identified during index ED evaluation. 30-day adjudicated serious outcomes were arrhythmic (arrhythmias, unknown cause of death) and non-arrhythmic (MI, structural heart disease, pulmonary embolism, hemorrhage)]. We compared the serious outcome proportion among risk categories using Cochran-Armitage test. Step-2: We conducted semi-structured interviews using observed risk to develop and refine the recommendations. We used purposive sampling of physicians involved in syncope care at 8 sites from Jun-Dec 2019 until theme saturation was reached. Two independent raters coded interviews using an inductive approach to identify themes; discrepancies were resolved by consensus. Results: Of the 8176 patients (mean age 54, 55% female), 293 (3.6%; 95%CI 3.2-4.0%) experienced 30-day serious outcomes; 0.4% deaths, 2.5% arrhythmic, 1.1% non-arrhythmic outcomes. The serious outcome proportion significantly increased from low to high-risk categories (p < 0.001; overall 0.6% to 27.7%; arrhythmic 0.2% to 17.3%; non-arrhythmic 0.4% to 5.9% respectively). C-statistic was 0.88 (95%CI0.86–0.90). Non-arrhythmia risk per day for the first 2 days was 0.5% for medium-risk, 2% for high-risk and very low thereafter. We recruited 31 physicians (14 ED, 7 cardiologists, 10 hospitalists/internists). 80% of physicians agreed that low risk patients can be discharged without specific follow-up with inconsistencies around length of ED observation. For cardiac monitoring of medium and high-risk, 64% indicated that they don't have access; 56% currently admit high-risk patients and an additional 20% agreed to this recommendation. A deeper exploration led to following refinement: discharge without specific follow-up for low-risk, a shared decision approach for medium-risk and short course of hospitalization for high-risk patients. Conclusion: The recommendations were developed (with online calculator) based on in-depth feedback from key stakeholders to improve uptake during implementation.

Prolonged Febrile Neutropenia in the Pediatric Patient with Cancer

2012 ◽  
pp. 565-569
Author(s):  
Andrew Y. Koh
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Pediatric Patients ◽  
Fungal Infections ◽  
Hematologic Malignancy ◽  
Infectious Complications ◽  
Great Promise ◽  
High Risk Patients ◽  
Patients With Cancer ◽  
Risk Patients

Overview: Infectious diseases continue to be major causes of morbidity and mortality in pediatric patients with cancer. Yet not all pediatric patients with cancer with fever and neutropenia are at equal risk for substantial morbidity or mortality from infection. Patients at highest risk for developing infectious complications are those with severe and prolonged neutropenia, substantial medical comorbidity, and hematologic malignancy, or recipients of stem-cell transplantation. These “high-risk” patients also have concomitant host immune deficits as well: severe mucositis, lymphopenia, hypogammaglobulinemia, and gut microbial dysbiosis. Because bacterial and fungal infections are the most common infectious complications, continuation of empirical antibacterial antibiotics that were initiated at the onset of febrile neutropenia and prompt initiation of empirical antifungal therapy in the setting of prolonged fever and neutropenia continue to be the standard of care. In high-risk patients, antibiotic therapy should be maintained until neutrophil counts have recovered. Adjunctive therapies have been shown to be ineffective (e.g., colony-stimulating factors) or necessitate further study (e.g., granulocyte infusions or keratinocyte growth factor treatment to heal mucositis). Prophylactic use of antibacterial and antifungal antibiotics in high-risk patients has shown promise but the fear of inducing antimicrobial-resistant strains remains a deterrent. Finally, the novel concepts of manipulating the host gut microbiota and/or augmenting GI mucosal immunity to prevent invasive bacterial and fungal infections in pediatric patients with cancer offers great promise, but more definitive studies need to be performed.

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