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.

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.

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

We will share de-identified participant data and supporting information with other researchers upon request to the PI.

Upon publication of the planned manuscripts. Data will be retained through February 2028.

Data will require completion of a data use agreement with Dartmouth.

physicians who enrolled in the trial

11 months

Heterogeneity of treatment effect across steps of the trial, suggesting the possibility of confounding secondary to the impact of COVID on hospital conditions.

Other limitations include: 1) generalizability of the results; 2) bias from non-random patterns of missingness in the data; 3) failure to systematically evaluate the fidelity and implementation of the intervention as planned due to COVID.

A hospital's treatment assignment was masked during analysis.