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

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

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.

Study Overview

• Status: Completed
• Conditions: Advance Care Planning
• Intervention / Treatment: Behavioral: Hopewell Hospitalist Video Game

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.

• Study Type: Interventional
• Enrollment (Actual): 163
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • New Hampshire
    • Lebanon, New Hampshire, United States, 03766
      • Dartmouth Hitchcock Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Usual Care Control; 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; 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; 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.

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

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hospitalist Advance Care Planning Attitudes Vignette-Based Measure	Responses to patient case vignettes by enrolled hospitalists' regarding patient priority for advance care planning conversation. For each vignette, enrolled hospitalists decide if and how a patient in a case vignette receives an advanced care planning conversation by selecting one of four responses categories: No, Primary Care Physician, Admit, or Now.	1 month
Hospitalist Advance Care Planning Attitudes Questionnaire-Based Measure	Individual and aggregated responses to 10-item questionnaire regarding enrolled hospitalists' attitudes towards advance care planning. Each of the ten items is a 5-point Likert scale. Higher scores indicate positive attitudes and lower scores indicate negative attitudes.	1 month

Collaborators and Investigators

• Sponsor: Dartmouth-Hitchcock Medical Center
• Collaborators: National Institute on Aging (NIA); Sound Physicians
• Investigators: Principal Investigator: Amber Barnato, MD, MPH, MS, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine�; Principal Investigator: Deepika Mohan, MD, MPH, University of Pittsburgh

Publications and helpful links

General Publications

• Mohan D, MacMartin MA, Chelen JSC, Maezes CB, Barnato AE. Development of a theory-based video-game intervention to increase advance care planning conversations by healthcare providers. Implement Sci Commun. 2021 Oct 13;2(1):117. doi: 10.1186/s43058-021-00216-8.
• Mohan D, O'Malley AJ, Chelen J, MacMartin M, Murphy M, Rudolph M, Barnato A. Videogame intervention to increase advance care planning conversations by hospitalists with older adults: study protocol for a stepped-wedge clinical trial. BMJ Open. 2021 Mar 22;11(3):e045084. doi: 10.1136/bmjopen-2020-045084.

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2020
• Primary Completion (Actual): May 31, 2021
• Study Completion (Actual): August 31, 2021

Study Registration Dates

• First Submitted: September 11, 2020
• First Submitted That Met QC Criteria: September 18, 2020
• First Posted (Actual): September 22, 2020

Study Record Updates

• Last Update Posted (Actual): April 10, 2023
• Last Update Submitted That Met QC Criteria: March 13, 2023
• Last Verified: March 1, 2023

More Information

Terms related to this study

• Keywords: advance care planning; serious games; physician performance; narrative engagement
• Other Study ID Numbers: STUDY00031186; P01AG019783 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: We will share de-identified participant data and supporting information with other researchers upon request to the PI.
• IPD Sharing Time Frame: Upon publication of the planned manuscripts. Data will be retained through February 2028.
• IPD Sharing Access Criteria: Data will require completion of a data use agreement with Dartmouth.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No