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Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial

IMPORTANCE: Serious illness conversations (SICs) between oncology clinicians and patients are associated with improved quality of life and may reduce aggressive end-of-life care. However, most patients with cancer die without a documented SIC. OBJECTIVE: To test the impact of behavioral nudges to cl...

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Autores principales: Manz, Christopher R., Zhang, Yichen, Chen, Kan, Long, Qi, Small, Dylan S., Evans, Chalanda N., Chivers, Corey, Regli, Susan H., Hanson, C. William, Bekelman, Justin E., Braun, Jennifer, Rareshide, Charles A. L., O’Connor, Nina, Kumar, Pallavi, Schuchter, Lynn M., Shulman, Lawrence N., Patel, Mitesh S., Parikh, Ravi B.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: American Medical Association 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9857721/
https://www.ncbi.nlm.nih.gov/pubmed/36633868
http://dx.doi.org/10.1001/jamaoncol.2022.6303
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author Manz, Christopher R.
Zhang, Yichen
Chen, Kan
Long, Qi
Small, Dylan S.
Evans, Chalanda N.
Chivers, Corey
Regli, Susan H.
Hanson, C. William
Bekelman, Justin E.
Braun, Jennifer
Rareshide, Charles A. L.
O’Connor, Nina
Kumar, Pallavi
Schuchter, Lynn M.
Shulman, Lawrence N.
Patel, Mitesh S.
Parikh, Ravi B.
author_facet Manz, Christopher R.
Zhang, Yichen
Chen, Kan
Long, Qi
Small, Dylan S.
Evans, Chalanda N.
Chivers, Corey
Regli, Susan H.
Hanson, C. William
Bekelman, Justin E.
Braun, Jennifer
Rareshide, Charles A. L.
O’Connor, Nina
Kumar, Pallavi
Schuchter, Lynn M.
Shulman, Lawrence N.
Patel, Mitesh S.
Parikh, Ravi B.
author_sort Manz, Christopher R.
collection PubMed
description IMPORTANCE: Serious illness conversations (SICs) between oncology clinicians and patients are associated with improved quality of life and may reduce aggressive end-of-life care. However, most patients with cancer die without a documented SIC. OBJECTIVE: To test the impact of behavioral nudges to clinicians to prompt SICs on the SIC rate and end-of-life outcomes among patients at high risk of death within 180 days (high-risk patients) as identified by a machine learning algorithm. DESIGN, SETTING, AND PARTICIPANTS: This prespecified 40-week analysis of a stepped-wedge randomized clinical trial conducted between June 17, 2019, and April 20, 2020 (including 16 weeks of intervention rollout and 24 weeks of follow-up), included 20 506 patients with cancer representing 41 021 encounters at 9 tertiary or community-based medical oncology clinics in a large academic health system. The current analyses were conducted from June 1, 2021, to May 31, 2022. INTERVENTION: High-risk patients were identified using a validated electronic health record machine learning algorithm to predict 6-month mortality. The intervention consisted of (1) weekly emails to clinicians comparing their SIC rates for all patients against peers’ rates, (2) weekly lists of high-risk patients, and (3) opt-out text messages to prompt SICs before encounters with high-risk patients. MAIN OUTCOMES AND MEASURES: The primary outcome was SIC rates for all and high-risk patient encounters; secondary end-of-life outcomes among decedents included inpatient death, hospice enrollment and length of stay, and intensive care unit admission and systemic therapy close to death. Intention-to-treat analyses were adjusted for clinic and wedge fixed effects and clustered at the oncologist level. RESULTS: The study included 20 506 patients (mean [SD] age, 60.0 [14.0] years) and 41 021 patient encounters: 22 259 (54%) encounters with female patients, 28 907 (70.5%) with non-Hispanic White patients, and 5520 (13.5%) with high-risk patients; 1417 patients (6.9%) died by the end of follow-up. There were no meaningful differences in demographic characteristics in the control and intervention periods. Among high-risk patient encounters, the unadjusted SIC rates were 3.4% (59 of 1754 encounters) in the control period and 13.5% (510 of 3765 encounters) in the intervention period. In adjusted analyses, the intervention was associated with increased SICs for all patients (adjusted odds ratio, 2.09 [95% CI, 1.53-2.87]; P < .001) and decreased end-of-life systemic therapy (7.5% [72 of 957 patients] vs 10.4% [24 of 231 patients]; adjusted odds ratio, 0.25 [95% CI, 0.11-0.57]; P = .001) relative to controls, but there was no effect on hospice enrollment or length of stay, inpatient death, or end-of-life ICU use. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, a machine learning–based behavioral intervention and behavioral nudges to clinicans led to an increase in SICs and reduction in end-of-life systemic therapy but no changes in other end-of-life outcomes among outpatients with cancer. These results suggest that machine learning and behavioral nudges can lead to long-lasting improvements in cancer care delivery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03984773
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spelling pubmed-98577212023-02-01 Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial Manz, Christopher R. Zhang, Yichen Chen, Kan Long, Qi Small, Dylan S. Evans, Chalanda N. Chivers, Corey Regli, Susan H. Hanson, C. William Bekelman, Justin E. Braun, Jennifer Rareshide, Charles A. L. O’Connor, Nina Kumar, Pallavi Schuchter, Lynn M. Shulman, Lawrence N. Patel, Mitesh S. Parikh, Ravi B. JAMA Oncol Brief Report IMPORTANCE: Serious illness conversations (SICs) between oncology clinicians and patients are associated with improved quality of life and may reduce aggressive end-of-life care. However, most patients with cancer die without a documented SIC. OBJECTIVE: To test the impact of behavioral nudges to clinicians to prompt SICs on the SIC rate and end-of-life outcomes among patients at high risk of death within 180 days (high-risk patients) as identified by a machine learning algorithm. DESIGN, SETTING, AND PARTICIPANTS: This prespecified 40-week analysis of a stepped-wedge randomized clinical trial conducted between June 17, 2019, and April 20, 2020 (including 16 weeks of intervention rollout and 24 weeks of follow-up), included 20 506 patients with cancer representing 41 021 encounters at 9 tertiary or community-based medical oncology clinics in a large academic health system. The current analyses were conducted from June 1, 2021, to May 31, 2022. INTERVENTION: High-risk patients were identified using a validated electronic health record machine learning algorithm to predict 6-month mortality. The intervention consisted of (1) weekly emails to clinicians comparing their SIC rates for all patients against peers’ rates, (2) weekly lists of high-risk patients, and (3) opt-out text messages to prompt SICs before encounters with high-risk patients. MAIN OUTCOMES AND MEASURES: The primary outcome was SIC rates for all and high-risk patient encounters; secondary end-of-life outcomes among decedents included inpatient death, hospice enrollment and length of stay, and intensive care unit admission and systemic therapy close to death. Intention-to-treat analyses were adjusted for clinic and wedge fixed effects and clustered at the oncologist level. RESULTS: The study included 20 506 patients (mean [SD] age, 60.0 [14.0] years) and 41 021 patient encounters: 22 259 (54%) encounters with female patients, 28 907 (70.5%) with non-Hispanic White patients, and 5520 (13.5%) with high-risk patients; 1417 patients (6.9%) died by the end of follow-up. There were no meaningful differences in demographic characteristics in the control and intervention periods. Among high-risk patient encounters, the unadjusted SIC rates were 3.4% (59 of 1754 encounters) in the control period and 13.5% (510 of 3765 encounters) in the intervention period. In adjusted analyses, the intervention was associated with increased SICs for all patients (adjusted odds ratio, 2.09 [95% CI, 1.53-2.87]; P < .001) and decreased end-of-life systemic therapy (7.5% [72 of 957 patients] vs 10.4% [24 of 231 patients]; adjusted odds ratio, 0.25 [95% CI, 0.11-0.57]; P = .001) relative to controls, but there was no effect on hospice enrollment or length of stay, inpatient death, or end-of-life ICU use. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, a machine learning–based behavioral intervention and behavioral nudges to clinicans led to an increase in SICs and reduction in end-of-life systemic therapy but no changes in other end-of-life outcomes among outpatients with cancer. These results suggest that machine learning and behavioral nudges can lead to long-lasting improvements in cancer care delivery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03984773 American Medical Association 2023-01-12 2023-03 /pmc/articles/PMC9857721/ /pubmed/36633868 http://dx.doi.org/10.1001/jamaoncol.2022.6303 Text en Copyright 2023 Manz CR et al. JAMA Oncology. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the terms of the CC-BY License.
spellingShingle Brief Report
Manz, Christopher R.
Zhang, Yichen
Chen, Kan
Long, Qi
Small, Dylan S.
Evans, Chalanda N.
Chivers, Corey
Regli, Susan H.
Hanson, C. William
Bekelman, Justin E.
Braun, Jennifer
Rareshide, Charles A. L.
O’Connor, Nina
Kumar, Pallavi
Schuchter, Lynn M.
Shulman, Lawrence N.
Patel, Mitesh S.
Parikh, Ravi B.
Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial
title Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial
title_full Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial
title_fullStr Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial
title_full_unstemmed Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial
title_short Long-term Effect of Machine Learning–Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial
title_sort long-term effect of machine learning–triggered behavioral nudges on serious illness conversations and end-of-life outcomes among patients with cancer: a randomized clinical trial
topic Brief Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9857721/
https://www.ncbi.nlm.nih.gov/pubmed/36633868
http://dx.doi.org/10.1001/jamaoncol.2022.6303
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