Patients with cancer often experience physical and emotional distress, utilize unplanned
acute care, and undergo medical interventions that are discordant with their wishes. Given
the Covid-19 pandemic, these adverse outcomes are amplified, particularly for racial/ethnic
minorities. Serious illness conversations (SICs) that elicit patients' values, goals, and
care preferences, particularly early in the disease trajectory, are an evidence-based
practice, improve patient mood and quality of life, and are recommended by national
guidelines. Preliminary data suggests that SICs among patients with cancer are associated
with improved quality of life, increased hospice utilization, and decreased acute care
utilization. However, most patients with advanced cancer die without a documented SIC and
there are well-documented health disparities in implementation for racial and ethnic
minorities. Current strategies to promote SICs, including the multi-component strategies of
the Serious Illness Conversation Program, focus primarily on clinician education and have
marginally increased the timeliness and frequency of SICs and reduced patient anxiety and
depression. While core elements of this program are transferable-such as its structured
guide-clinical use remains low. For example, even after training, clinicians at Penn Medicine
document SICs for fewer than 5% of patients with advanced cancer. There is critical need to
develop, test, and disseminate strategies to improve the frequency of SICs.
Implementation strategies informed by behavioral economics are ideally suited to address this
problem, which is fundamentally one of clinician and patient behavior change. Clinician
barriers to initiating SICs include optimism bias, or the belief that one's own patient is
unlikely to experience a negative event; uncertainty about prognosis and appropriate timing;
and fear that bringing up end-of-life issues may be distressing to patients. Patient barriers
to SIC initiation include fear of discussing the end of life and beliefs that SICs are not
appropriate until late in the course of cancer. While previous studies have tested financial
incentives for SIC documentation, little research has evaluated behavioral economics-informed
strategies to align both clinicians and patients towards earlier SICs.
By intentionally modifying the way choices are framed, behavioral nudges can lead to
desirable changes in clinician behavior while preserving clinician choice. The investigators'
preliminary work demonstrates the effectiveness of an implementation strategy focusing on a
clinician nudge, consisting of performance feedback and targeted text messages identifying
patients at high risk of mortality based on a validated machine learning prognostic
algorithm. This strategy led to a threefold increase in SIC documentation for high-risk
patients, equitably across racial/ethnic minority subgroups, and is now in routine use across
Penn Medicine practice sites. However, clinicians still did not document SICs for over half
of patients, illustrating the limitations of a clinician-directed implementation strategy
alone.
This study will expand on these preliminary findings to evaluate the synergy between
clinician- and patient-directed nudges to increase SIC documentation. The main purpose of
this research study is to evaluate the effectiveness of nudges to clinicians, to patients, or
to both in increasing Serious Illness Conversation (SIC) documentation; and to identify
moderators of implementation effects on SIC documentation. The investigators will employ
rapid-cycle approaches to optimize the framing of nudges to clinicians and patients prior to
initiating the trial and mixed methods to explore contextual factors and mechanisms. The
investigators will conduct a four-arm pragmatic cluster randomize clinical trial to test the
effectiveness of nudges to clinicians, nudges to patients, or nudges to both in increasing
the frequency and timeliness of SIC documentation in cancer patients vs. usual care (UC).
Rationale for clinician nudge using mortality prediction and peer comparison: Due to optimism
bias, clinicians routinely overestimate the life expectancy of patients with advanced cancer
and delay SICs until too late in the disease course. In part because of this, clinicians
reinforce a social norm that early SICs are not part of routine oncology care. Providing an
objective assessment of predicted mortality risk may help counteract optimism bias among
clinicians and help them identify patients most likely to benefit from SICs. Moreover, that
individuals desire to conform to an approved behavior (an injunctive norm) and the behavior
of others (a descriptive norm) may contribute to low observed SIC rates, and may also afford
an opportunity for intervention. The investigators expect that periodically reminding
clinicians of their own performance on SIC documentation, while providing both an injunctive
norm (citing national and institutional guidelines) and a descriptive social norm (displaying
the behavior of their best performing peers), will lead clinicians to conform more closely to
these norms, as has been shown in studies conducted in other contexts.
Rationale for patient nudge using priming: Priming is a type of nudge that frames information
to activate one's self-efficacy and willingness to engage in behavior change. This type of
nudge has not previously been evaluated as a tool to promote SICs for patients with cancer.
The investigators will test the added impact of a patient nudge designed to prime patients
and, in turn, their clinicians to having a SIC.
