EFFICACY: Hopewell Hospitalist: A Video Game Intervention to Increase Advance Care Planning by Hospitalists

Study Overview
=================
Brief Summary
-----------------
Hopewell Hospitalist is a theory-based adventure video game designed to increase the likelihood that a physician will engage in an advance care planning (ACP) conversation with a patient over the age of 65. Drawing on the theory of narrative engagement, players assume the persona of a hospitalist and navigate a series of clinical encounters with seriously-ill patients over the age of 65. Players experience the consequences of having (or not having) ACP conversations in a timely fashion. The planned study is a pragmatic stepped-wedge crossover phase III trial testing the efficacy of Hopewell Hospitalist for increasing ACP rates measured by ACP billing frequency.

Detailed Description
-----------------
Introduction: Fewer than half of all people in the U.S. have a documented advance care plan, such as an advance directive, despite their importance in ensuring high-quality care at the end-of-life. Hospitalization offers an opportunity for physicians to initiate advance care planning (ACP) conversations. Despite expert recommendations, hospital-based physicians (hospitalists) do not routinely engage in these conversations, reserving them for the critically ill. The objective of this study is to test the effect of a novel behavioral intervention on the incidence of ACP conversations by hospitalists practicing at a stratified random sample of hospitals drawn from 220 US acute care hospitals staffed by a large, nationwide acute care physician practice with an ongoing ACP quality improvement initiative. Methods and analysis: We developed Hopewell Hospitalist, a theory-based adventure video game, to modify physicians' attitudes towards ACP conversations, and to increase their motivation for engaging in them. Drawing on the theory of narrative engagement, players assume the persona of Andy Jordan, a hospitalist who accepts a new job in a small town. Through a series of clinical encounters with seriously-ill patients over the age of 65, players experience the consequences of having (or not having) ACP conversations in a timely fashion. The planned study is a pragmatic stepped-wedge crossover phase III trial, testing the efficacy of Hopewell Hospitalist for increasing ACP conversations. We will randomize 40 hospitals to the month (step) in which they receive the intervention. We aim to recruit 30 hospitalists from up to 8 hospitals each step to complete the intervention, playing Hopewell Hospitalist for at least 2 hours on an iPad pre-loaded with the game. The primary outcome is ACP billing for patients age 65 and older managed by participating hospitalists. We hypothesize that the intervention will increase ACP billing in the quarter after dissemination, and have 80% power to detect a 1% absolute increase and 99% power to detect a 3.5% absolute increase. Ethics and dissemination: Dartmouth's Committee for the Protection of Human Subjects has approved the study protocol, which is registered on clinicaltrials.gov. We will disseminate the results through manuscripts and the trials website. Hopewell Hospitalist will be made available on the iOS Application Store for download, free of cost, at the conclusion of the trial.

Official Title
-----------------
Hopewell Hospitalist: A Video Game Intervention to Increase Advance Care Planning Conversations by Hospitalists With Older Adults

Conditions
-----------------
Advance Care Planning

Intervention / Treatment
-----------------
* Behavioral: Hopewell Hospitalist Video Game


Participation Criteria
=================
Eligibility Criteria
-----------------
Hospital Inclusion Criteria: Value-based delivery model of care (Bundled Payment Care Initiative) Staffed by Sound Physicians for at least 2 quarters Advance care planning billing rate in prior quarter greater than 0 percent Employs a nurse liaison Hospitalist chief approval to approach hospitalists Hospital Exclusion Criteria: Sound Physicians no longer staffing the hospital Not staffed by Sound Physicians for at least 2 quarters Advance care planning billing rate in prior quarter of 0 percent Does not employ a nurse liaison Hospitalist chief disapproval to approach hospitalists Hospitalist chief does not provide contact information for hospitalists Target number of hospitalists for the step has been met or exceeded Hospitalist Inclusion Criteria: Employed by Sound for at least 2 quarters and staffing an eligible hospital for at least 1 quarter ACP billing rate in prior quarter greater than 0 percent or answers eligibility question affirming use of ACP billing codes Provides informed consent Name matches a name in the contact list for the sample; OR is verified by communication through an employer-based email address Receipt of a functional iPad within study step time frame Hospitalist Exclusion Criteria: Not employed by Sound for at least 2 quarters and staffing an eligible hospital for at least 1 quarter ACP billing rate in prior quarter of 0 percent or answers eligibility question refusing use of ACP billing Does not provide informed consent Provides consent after the given deadline for consenting Name does not match a name in the contact list for the sample; OR cannot be verified by communication through an employer-based email address Receipt of a nonfunctional iPad within study step time frame If the number of participants who consent per site exceeds targets, then participants who are part-time employees will be preferentially excluded
Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: A stepped wedge crossover trial randomizing physician participants at the group level (i.e., hospital). Each hospital group 'crossed over' from control to intervention at a randomized time point.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Usual Care Control<br>The control arm occurred prior to receipt of the video game intervention. Each hospital group 'crossed over' from control to intervention at a randomized time point based on their assignment to the 'step' of the trial. | |
| Experimental: Video Game Intervention<br>Each hospital group 'crossed over' from control to intervention at a randomized time point. Physicians working at these hospitals, who agreed to participate in the trial, received a study iPad and were asked to play the video game loaded on the iPad for a minimum of 2 hours. | Behavioral: Hopewell Hospitalist Video Game<br>* Hopewell Hospitalist is a customized theory-based adventure video game that uses narrative engagement to educate physician players on advance care planning to increase physicians' likelihood of engaging in and billing for ACP conversations.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percentage of Patients With Advance Care Planning Bills | Percentage of advance care planning bills submitted by physicians in the trial for patients over the age of 65 in the period before and after the roll-out of the video game intervention at their hospital. Advance care planning bills are defined as the presence/absence of ACP charges (Medicare billing codes 99497 or 99498) during a patient's hospitalization. | 11 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percentage of Patients Who Died While in Hospital | Number of patients who died in the pre-intervention and post-intervention period/total number of patients for both periods | 11 months | 
| Percentage of Patients Readmitted in 7 Days | Number of patients readmitted within 7 days/Total number of patients treated in the pre-intervention and post-intervention periods | 11 months | 
| Percentage of Patients Readmitted Within 30-days | Number of patients readmitted within 30-days/Total number of patients in the pre-intervention and post-intervention periods | 11 months | 
| Percentage of Patients Who Received Critical Care | Number of patients who received critical care while admitted/total number of patients admitted in the pre-intervention and post-intervention periods | 11 months | 
| Length of Stay | Duration of hospitalization for patients treated in the pre-intervention and post-intervention periods | 11 months | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
advance care planning, physician performance, serious games, narrative engagement