Amber E. Barnato

Use of Cardiac Implantable Electronic Devices in Older Adults With Cognitive Impairment

Older adults with mild cognitive impairment (MCI) and dementia have cardiac comorbidities, making them eligible for device-based therapy for cardiac rhythm abnormalities.1-3 The risks and benefits of device implantation should be weighed carefully by pa tients with cognitive impairment, family members, and clinicians given the potential of these devices to have an impact on the quantity and quality of life. This study describes the epidemiology of cardiac implantable electronic devices among a population-based sample of older adults with and without cognitive impairment.

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial

Abstract Objective To determine whether a behavioral intervention delivered through a video game can improve the appropriateness of trauma triage decisions in the emergency department of non-trauma centers. Design Randomized clinical trial. Setting Online intervention in national sample of emergency medicine physicians who make triage decisions at US hospitals. Participants 368 emergency medicine physicians primarily working at non-trauma centers. A random sample (n=200) of those with primary outcome data was reassessed at six months. Interventions Physicians were randomized in a 1:1 ratio to one hour of exposure to an adventure video game (Night Shift) or apps based on traditional didactic education (myATLS and Trauma Life Support MCQ Review), both on iPads. Night Shift was developed to recalibrate the process of using pattern recognition to recognize moderate-severe injuries (representativeness heuristics) through the use of stories to promote behavior change (narrative engagement). Physicians were randomized with a 2×2 factorial design to intervention (game v traditional education apps) and then to the experimental condition under which they completed the outcome assessment tool (low v high cognitive load). Blinding could not be maintained after allocation but group assignment was masked during the analysis phase. Main outcome measures Outcomes of a virtual simulation that included 10 cases; in four of these the patients had severe injuries. Participants completed the simulation within four weeks of their intervention. Decisions to admit, discharge, or transfer were measured. The proportion of patients under-triaged (patients with severe injuries not transferred to a trauma center) was calculated then (primary outcome) and again six months later, with a different set of cases (primary outcome of follow-up study). The secondary outcome was effect of cognitive load on under-triage. Results 149 (81%) physicians in the game arm and 148 (80%) in the traditional education arm completed the trial. Of these, 64/100 (64%) and 58/100 (58%), respectively, completed reassessment at six months. The mean age was 40 (SD 8.9), 283 (96%) were trained in emergency medicine, and 207 (70%) were ATLS (advanced trauma life support) certified. Physicians exposed to the game under-triaged fewer severely injured patients than those exposed to didactic education (316/596 (0.53) v 377/592 (0.64), estimated difference 0.11, 95% confidence interval 0.05 to 0.16; P<0.001). Cognitive load did not influence under-triage (161/308 (0.53) v 155/288 (0.54) in the game arm; 197/300 (0.66) v 180/292 (0.62) in the traditional educational apps arm; P=0.66). At six months, physicians exposed to the game remained less likely to under-triage patients (146/256 (0.57) v 172/232 (0.74), estimated difference 0.17, 0.09 to 0.25; P<0.001). No physician reported side effects. The sample might not reflect all emergency medicine physicians, and a small set of cases was used to assess performance. Conclusions Compared with apps based on traditional didactic education, exposure of physicians to a theoretically grounded video game improved triage decision making in a validated virtual simulation. Though the observed effect was large, the wide confidence intervals include the possibility of a small benefit, and the real world efficacy of this intervention remains uncertain. Trial registration clinicaltrials.gov; NCT02857348 (initial study)/NCT03138304 (follow-up).

Identifying Strategies for Effective Telemedicine Use in Intensive Care Units: The ConnECCT Study Protocol

Telemedicine, the use of audiovisual technology to provide health care from a remote location, is increasingly used in intensive care units (ICUs). However, studies evaluating the impact of ICU telemedicine show mixed results, with some studies demonstrating improved patient outcomes, while others show limited benefit or even harm. Little is known about the mechanisms that influence variation in ICU telemedicine effectiveness, leaving providers without guidance on how to best use this potentially transformative technology. The Contributors to Effective Critical Care Telemedicine (ConnECCT) study aims to fill this knowledge gap by identifying the clinical and organizational factors associated with variation in ICU telemedicine effectiveness, as well as exploring the clinical contexts and provider perceptions of ICU telemedicine use and its impact on patient outcomes, using a range of qualitative methods. In this report, we describe the study protocol, data collection methods, and planned future analyses of the ConnECCT study. Over the course of 1 year, the study team visited purposefully sampled health systems across the United States that have adopted telemedicine. Data collection methods included direct observations, interviews, focus groups, and artifact collection. Data were collected at the ICUs that provide in-person critical care as well as at the supporting telemedicine units. Iterative thematic content analysis will be used to identify and define key constructs related to telemedicine effectiveness and describe the relationship between them. Ultimately, the study results will provide a framework for more effective implementation of ICU telemedicine, leading to improved clinical outcomes for critically ill patients.

Challenges In Understanding And Respecting Patients’ Preferences

The Institute of Medicines report on Dying in America called for honoring treatment preferences near the end of life for seriously ill patients. To achieve this objective, the report recommended that patients, their family members, other loved ones, and providers engage in shared decision making about current and future treatment decisions (that is, advance care planning). Yet decision science research suggests that preferences are objectively difficult to specify for complex contingencies and subjectively difficult to specify for unfamiliar choices. Because advance care planning involves both difficulties-the future may unfold in complex ways and pose unprecedented choices-it may not fully and faithfully specify patients preferences. I discuss a powerful but overlooked influence on this planning: local providers practice norms. Norms often begin as generally accepted procedures but evolve into rules enforced by both external and internal sanctions (such as shame and pride). Local practice norms regarding the timing, content, and interpretation of advance care planning conversations influence patient choice. While the influence of providers on patients decisions cannot be entirely removed, I recommend increasing providers awareness of this influence by using audit, feedback, and coaching and by systematizing processes for advance care planning.

Using incentives to recruit physicians into behavioral trials: lessons learned from four studies

AbstractObjectiveTo describe lessons learned from the use of different strategies for recruiting physicians responsible for trauma triage, we summarize recruitment data from four behavioral trials run in the United States between 2010 and 2016.ResultsWe ran a series of behavioral trials with the primary objective of understanding the influence of heuristics on physician decision making in trauma triage. Three studies were observational; one tested an intervention. The trials used different methods of recruitment (in-person vs. email), timing of the honorarium (pre-paid vs. conditional on completion), type of honorarium [a

Serious games may improve physician heuristics in trauma triage

100 gift card (monetary reward) vs. an iPad mini 2 (material incentive)], and study tasks (a vignette-based questionnaire, virtual simulation, and intervention plus virtual simulation). We recruited 989 physicians, asking each to complete a questionnaire or virtual simulation online. Recruitment and response rates were 80% in the study where we approached physicians in person, used a pre-paid material incentive, and required that they complete both an intervention plus a virtual simulation. They were 56% when we recruited physicians via email, used a monetary incentive conditional on completion of the task, and required that they complete a vignette-based questionnaire.n Trial registration clinicaltrials.gov; NCT02857348

Identification of Facilitators and Barriers to Residents' Use of a Clinical Reasoning Tool

Significance Americans can expect to experience at least one meaningful diagnostic medical error in their lifetime. One plausible source of those errors is physicians’ reliance on heuristics that are generally useful but can fail in diagnostically challenging situations. Based on previous research and clinical experience, we identified heuristics that might cause diagnostic errors in trauma triage. We sought to improve physicians’ heuristic judgment by providing simulated experience with two “serious” video games. In a randomized controlled trial, both games had positive effects, whereas equivalent exposure to traditional medical education had none. By complementing physicians’ natural ways of thinking, such simulated experiences might transfer to actual triage and other high-pressure decisions. Trauma triage depends on fallible human judgment. We created two “serious” video game training interventions to improve that judgment. The interventions’ central theoretical construct was the representativeness heuristic, which, in trauma triage, would mean judging the severity of an injury by how well it captures (or “represents”) the key features of archetypes of cases requiring transfer to a trauma center. Drawing on clinical experience, medical records, and an expert panel, we identified features characteristic of representative and nonrepresentative cases. The two interventions instantiated both kinds of cases. One was an adventure game, seeking narrative engagement; the second was a puzzle-based game, emphasizing analogical reasoning. Both incorporated feedback on diagnostic errors, explaining their sources and consequences. In a four-arm study, they were compared with an intervention using traditional text-based continuing medical education materials (active control) and a no-intervention (passive control) condition. A sample of 320 physicians working at nontrauma centers in the United States was recruited and randomized to a study arm. The primary outcome was performance on a validated virtual simulation, measured as the proportion of undertriaged patients, defined as ones who had severe injuries (according to American College of Surgeons guidelines) but were not transferred. Compared with the control group, physicians exposed to either game undertriaged fewer such patients [difference = −18%, 95% CI: −30 to −6%, P = 0.002 (adventure game); −17%, 95% CI: −28 to −6%, P = 0.003 (puzzle game)]; those exposed to the text-based education undertriaged similar proportions (difference = +8%, 95% CI: −3 to +19%, P = 0.15).

I'm Not Sure We Had A Choice?: Decision Quality and The Use of Cardiac Implantable Electronic Devices In Older Adults With Cognitive Impairment

Abstract Background: While there is some experimental evidence to support the use of cognitive forcing strategies to reduce diagnostic error in residents, the potential usability of such strategies in the clinical setting has not been explored. We sought to test the effect of a clinical reasoning tool on diagnostic accuracy and to obtain feedback on its usability and acceptability. Methods: We conducted a randomized behavioral experiment testing the effect of this tool on diagnostic accuracy on written cases among post-graduate 3 (PGY-3) residents at a single internal medical residency program in 2014. Residents completed written clinical cases in a proctored setting with and without prompts to use the tool. The tool encouraged reflection on concordant and discordant aspects of each case. We used random effects regression to assess the effect of the tool on diagnostic accuracy of the independent case sets, controlling for case complexity. We then conducted audiotaped structured focus group debriefing sessions and reviewed the tapes for facilitators and barriers to use of the tool. Results: Of 51 eligible PGY-3 residents, 34 (67%) participated in the study. The average diagnostic accuracy increased from 52% to 60% with the tool, a difference that just met the test for statistical significance in adjusted analyses (p=0.05). Residents reported that the tool was generally acceptable and understandable but did not recognize its utility for use with simple cases, suggesting the presence of overconfidence bias. Conclusions: A clinical reasoning tool improved residents’ diagnostic accuracy on written cases. Overconfidence bias is a potential barrier to its use in the clinical setting.

Hospital-Based Physicians’ Intubation Decisions and Associated Mental Models when Managing a Critically and Terminally Ill Older Patient

Background The decision to implant a cardiac device in a person with Alzheimer’s disease or related dementia requires considering the possible trade-offs of quality of life (QOL) and quantity of life. This study measured the decision-making experience of patients with and without cognitive impairment (CI) who received a cardiac device and their family members who were involved in the decision. Methods and Results Semi-structured interviews and questionnaires were administered with 15 patient-family member dyads. Interviews revealed few conversations between physicians, patients and family members about the patient’s cognitive status or about the benefits, risks, and long-term implications of the device for someone with CI. Participants largely stated that the decision to get the device was based on the patient’s functional status at the time of the implant, and not on expectations about future functioning. Patients with CI had more regret, measured with the Decision Regret Scale (DRS), (p=0.037) and family members of patients without CI reported more decisional conflict, measured with the Decisional Conflict Scale (p=0.057). Conclusions Although CI impacts life expectancy and QOL, cognitive status was largely not discussed prior to device implant. Few differences were found between the experiences of dyads that included patients with or without CI.

Determinants of Intensive Care Unit Telemedicine Effectiveness: An Ethnographic Study

Background. Variation in the intensity of acute care treatment at the end of life is influenced more strongly by hospital and provider characteristics than patient preferences. Objective. We sought to describe physicians’ mental models (i.e., thought processes) when encountering a simulated critically and terminally ill older patient, and to compare those models based on whether their treatment plan was patient preference-concordant or preference-discordant. Methods. Seventy-three hospital-based physicians from 3 academic medical centers engaged in a simulated patient encounter and completed a mental model interview while watching the video recording of their encounter. We used an “expert” model to code the interviews. We then used Kruskal–Wallis tests to compare the weighted mental model themes of physicians who provided preference-concordant treatment with those who provided preference-discordant treatment. Results. Sixty-six (90%) physicians provided preference-concordant treatment and 7 (10%) provided preference-discordant treatment (i.e., they intubated the patient). Physicians who intubated the patient were more likely to emphasize the reversible and emergent nature of the patient situation (z = −2.111, P = 0.035), their own comfort (z = −2.764, P = 0.006), and rarely focused on explicit patient preferences (z = 2.380, P = 0.017). Limitations. Post-decisional interviewing with audio/video prompting may induce hindsight bias. The expert model has not yet been validated and may not be exhaustive. The small sample size limits generalizability and power. Conclusions. Hospital-based physicians providing preference-discordant used a different mental model for decision making for a critically and terminally ill simulated case. These differences may offer targets for future interventions to promote preference-concordant care for seriously ill patients.