Nudging both clinicians and patients may increase serious illness conversations

Combining clinician- and patient-directed nudges may help to promote serious illness conversations (SICs) in cancer care, according to a study published online July 1 in JAMA Network Open.

Samuel U. Takvorian, M.D., from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues randomly assigned clinician clusters and patients to receive usual care versus nudges, resulting in four arms:

• Active control, operating for two years prior to trial start, consisting of clinician text message reminders to complete SICs for patients at high mortality risk;
• Clinician nudge only, consisting of active control plus weekly peer comparisons of clinician-level SIC completion rates;
• Patient nudge only, consisting of active control plus a preclinic electronic communication to prime patients for SICs;
• and combined clinician and patient nudges.

The analysis included 4,450 patients at high risk for mortality seen by 163 clinicians at oncology clinics across four hospitals and six community sites within a large academic health system.

The researchers found that overall patient-level rates of six-month SIC completion were 11.2% for the active control arm, 11.5% for the clinician nudge arm, 11.5% for the patient nudge arm, and 14.1% for the combined nudge arm.

The combined nudges were associated with an increase in SIC rates (ratio of hazard ratios [rHR], 1.55; 95% confidence interval [CI], 1.00 to 2.40; P = 0.049) compared with active control. However, the clinician nudge (HR, 0.95; 95% CI, 0.64 to 1.41; P = 0.79) and patient nudge (HR, 0.99; 95% CI, 0.73 to 1.33; P = 0.93) were not associated with increased SIC rates.

"Our study may encourage future implementation strategies to improve goals of care documentation and patient-clinician communication more broadly," the authors write.

Several authors disclosed ties to the pharmaceutical industry.

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