While certain aspects of life look more like they did before the pandemic, life as a health care practitioner remains decidedly changed today, nearly three years after COVID-19 arrived in the United States.
After working long hours and seeing so many sickened, burnout risk is exceptionally high for clinicians across the United States, said M. Kit Delgado, MD, an assistant professor of Emergency Medicine and Epidemiology in the Perelman School of Medicine at the University of Pennsylvania.
Tied to the complications related to burnout, Delgado pointed to a new study in JAMA Open that shows that the rate at which patients leave United States emergency departments without being seen due to has doubled. In the busiest hospitals, 10 of every 100 patients who visit the emergency department can’t make it in from the waiting room because the hospital is stretched beyond capacity, the study indicated.
“That’s emblematic of a national problem in which the current demand for acute care far exceeds the capacity of our country’s current health care system and its ability for public health prevention measures,” Delgado said.
These are among the challenges that Delgado is extra aware of as he settles into the first few months of leading Penn Medicine’s renowned Nudge Unit.
Founded by Mitesh Patel, MD, the Nudge Unit — which focuses on designing slight pushes that help people make better, healthier, or just more-optimal decisions — has often gotten attention for its work in increasing exercise, improving prescription practices, and improving health screening rates. In the wake of COVID, Delgado hopes to push the Nudge Unit firmly into the territory of making health care workers’ lives easier. A heavy focus of that is lessening the load they carry.
“There needs to be a focus on interventions that make it easier for clinicians to help patients access the preventive care they need and safely manage their acute care needs outside of the hospital,” Delgado said. “Solutions in these areas will be difference-makers.”
In the past, the Nudge Unit has implemented measures to help cut down on clinician tasks, which almost always also improve patient outcomes. For example, one intervention published earlier this year doubled hepatitis C screenings among eligible patients. Nudges like this provide a clue into how Delgado and his team could continue the drive to make doctors’, nurses’, and other staff’s lives easier.
Pilot Projects: Nudges to Make Clinician Decisions Easier, Improve Diagnosis, and More
In some of the new pilot projects already announced as part of a request for proposals that went out earlier this year, this focus on easing the work of clinicians can be picked out among the obvious benefits to patients they’re designed to bring.
For instance, two projects co-led by Marty Peifer, MD, the associate medical director of the clinical informatics primary care service line, and her team members seek to automate nudges to screen for sneaky but treatable conditions that lead to significant health problems such as primary aldosteronism (a common cause of uncontrolled high blood pressure) and primary hyperparathyroidism (a common cause of osteoporosis and kidney stones). The plan is to accomplish this using algorithms with data pulled from electronic health records.
A different project led by Alex Fanaroff, MD, an assistant professor of Cardiology, and Mili Mehta, MD, a fellow in Cardiovascular Disease, seeks to make it easier to increase medication adherence for statin medication by setting a default prescription amount to cover 90 days (as opposed to 30 days) in some clinics. The Nudge Unit has deployed similar default approaches to successfully increase rates of generic prescriptions.
Another project led by Rebecca Hamm, MD, an assistant professor of Obstetrics and Gynecology, will implement a nudge to prompt the use of an “evidence-based calculator” that could provide decision support to clinicians. For patients at the low end of the risk spectrum, use of this calculator can empower the patient and their clinicians to achieve vaginal deliveries and avoid unnecessary c-sections. At the high end of the risk spectrum, the calculator could enable a faster decision for proceeding with c-section and prevent complications.
Implementation Science Focus
Projects like Hamm’s benefit from the work of Delgado’s direct predecessor, Rinad Beidas, PhD, the Nudge Unit’s second director, who was also the director of the Penn Implementation Science Center in the Leonard Davis Institute of Health Economics. Implementation science is the practice of rapidly implementing and monitoring evidence-based practices to achieve positive changes.
“Rinad brought in an immense amount of expertise in implementation science, which is very complementary to the core idea of nudging,” Delgado said. “Early in the design process for a nudge, we can leverage insights from implementation science to ensure that our interventions will scale. And when a nudge is successful, strategies from implementation science can help us promote uptake by clinicians and patients to maximize impact and ensure sustainment."
Emphasizing Equity
Another focus that Delgado is hoping to make a “guidepost” is achieving equity in the outcomes of the unit’s interventions.
“This will involve prioritizing projects in which significant equity gaps exist, designing interventions that can close those gaps, and devising evaluation protocols to assess how interventions perform overall and by demographic group,” said Delgado.
A project selected for launch in 2023 (led by Sara Ginzberg, MD, a surgery resident, Christine Edmonds, MD, an assistant professor in Radiology, and Lola Fayanju, MD, an associate professor in Surgery and chief of Breast Surgery) that falls in the category of prioritizing equity is one that seeks to make ordering a biopsy the default option in the electronic health record when high-risk abnormalities are detected in breast imaging. Along with reducing the time physicians need to spend in the health record and improving the time to diagnosis, the project seeks to address national racial gaps in breast cancer diagnosis and subsequent outcomes.
Delgado isn’t tricking himself into thinking things in health care will reach pre-pandemic status soon, if ever again.
But he feels that the Nudge Unit is uniquely positioned to improve on whatever normal is now. It has already made strides in issues that were compounded by COVID-19, such as physician workloads, and Delgado personally worked on multiple projects involving opioids, the epidemic that preceded the pandemic and which he plans to continue working on.
“My mission is to design systems or choice environments that make the best choice the easy choice,” Delgado said. “I think the Nudge Unit’s combination of talent and relationships within the health system and the university make it perfectly situated to have a positive impact.”