Using a Video Game Intervention to Increase Hospitalists' Advance Care Planning Conversations with Older Adults: a Stepped Wedge Randomized Clinical Trial

Abstract

Background: Guidelines recommend Advance Care Planning (ACP) for seriously ill older adults to increase the patient-centeredness of end-of-life care. Few interventions target the inpatient setting.

Objective: To test the effect of a novel physician-directed intervention on ACP conversations in the inpatient setting.

Design: Stepped wedge cluster-randomized design with five 1-month steps (October 2020-February 2021), and 3-month extensions at each end.

Setting: A total of 35/125 hospitals staffed by a nationwide physician practice with an existing quality improvement initiative to increase ACP (enhanced usual care).

Participants: Physicians employed for ≥ 6 months at these hospitals; patients aged ≥ 65 years they treated between July 2020-May 2021.

Intervention: Greater than or equal to 2 h of exposure to a theory-based video game designed to increase autonomous motivation for ACP; enhanced usual care.

Main measure: ACP billing (data abstractors blinded to intervention status).

Results: A total of 163/319 (52%) invited, eligible hospitalists consented to participate, 161 (98%) responded, and 132 (81%) completed all tasks. Physicians' mean age was 40 (SD 7); most were male (76%), Asian (52%), and reported playing the game for ≥ 2 h (81%). These physicians treated 44,235 eligible patients over the entire study period. Most patients (57%) were ≥ 75; 15% had COVID. ACP billing decreased between the pre- and post-intervention periods (26% v. 21%). After adjustment, the homogeneous effect of the game on ACP billing was non-significant (OR 0.96; 95% CI 0.88-1.06; p = 0.42). There was effect modification by step (p < 0.001), with the game associated with increased billing in steps 1-3 (OR 1.03 [step 1]; OR 1.15 [step 2]; OR 1.13 [step 3]) and decreased billing in steps 4-5 (OR 0.66 [step 4]; OR 0.95 [step 5]).

Conclusions: When added to enhanced usual care, a novel video game intervention had no clear effect on ACP billing, but variation across steps of the trial raised concerns about confounding from secular trends (i.e., COVID).

Trial registration: Clinicaltrials.gov; NCT04557930, 9/21/2020.

Keywords: ACP; physician behavior.; video game.