Cognitive Biases Influence Decision-Making Regarding Postacute Care in a Skilled Nursing Facility
BACKGROUND: Decisions about postacute care are increasingly important as the United States population ages, its use becomes increasingly common, and payment reforms target postacute care. However, little is known about how to improve these decisions.
OBJECTIVE: To understand whether cognitive biases play an important role in patient and clinician decision-making regarding postacute care in skilled nursing facilities (SNFs) and identify the most impactful biases.
DESIGN: Secondary analysis of 105 semistructured interviews with patients, caregivers, and clinicians.
SETTING: Three hospitals and three SNFs in a single metropolitan area.
PATIENTS: Adults over age 65 discharged to SNFs after hospitalization as well as patients, caregivers, and multidisciplinary frontline clinicians in both hospital and SNF settings.
MEASUREMENTS: We identified potential cognitive biases from prior systematic and narrative reviews and conducted a team-based framework analysis of interview transcripts to identify potential biases.
RESULTS: Authority bias/halo effect and framing bias were the most prevalent and seemed the most impactful, while default/status quo bias and anchoring bias were also present in decision-making about SNFs.
CONCLUSIONS: Cognitive biases play an important role in decision-making about postacute care in SNFs. The combination of authority bias/halo effect and framing bias may synergistically increase the likelihood of patients accepting SNFs for postacute care. As postacute care undergoes a transformation spurred by payment reforms, it is increasingly important to ensure that patients understand their choices at hospital discharge and can make high-quality decisions consistent with their goals.
© 2020 Society of Hospital Medicine
The combination of decreasing hospital lengths of stay and increasing age and comorbidity of the United States population is a principal driver of the increased use of postacute care in the US.1-3 Postacute care refers to care in long-term acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities (SNFs), and care provided by home health agencies after an acute hospitalization. In 2016, 43% of Medicare beneficiaries received postacute care after hospital discharge at the cost of $60 billion annually; nearly half of these received care in an SNF.4 Increasing recognition of the significant cost and poor outcomes of postacute care led to payment reforms, such as bundled payments, that incentivized less expensive forms of postacute care and improvements in outcomes.5-9 Early evaluations suggested that hospitals are sensitive to these reforms and responded by significantly decreasing SNF utilization.10,11 It remains unclear whether this was safe and effective.
In this context, increased attention to how hospital clinicians and hospitalized patients decide whether to use postacute care (and what form to use) is appropriate since the effect of payment reforms could negatively impact vulnerable populations of older adults without adequate protection.12 Suboptimal decision-making can drive both overuse and inappropriate underuse of this expensive medical resource. Initial evidence suggests that patients and clinicians are poorly equipped to make high-quality decisions about postacute care, with significant deficits in both the decision-making process and content.13-16 While these gaps are important to address, they may only be part of the problem. The fields of cognitive psychology and behavioral economics have revealed new insights into decision-making, demonstrating that people deviate from rational decision-making in predictable ways, termed decision heuristics, or cognitive biases.17 This growing field of research suggests heuristics or biases play important roles in decision-making and determining behavior, particularly in situations where there may be little information provided and the patient is stressed, tired, and ill—precisely like deciding on postacute care.18 However, it is currently unknown whether cognitive biases are at play when making hospital discharge decisions.
We sought to identify the most salient heuristics or cognitive biases patients may utilize when making decisions about postacute care at the end of their hospitalization and ways clinicians may contribute to these biases. The overall goal was to derive insights for improving postacute care decision-making.
