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 VA wouldn’t license [an SNF] if they didn’t have a good reputation for care, cleanliness, things of that nature” (Veteran, VA CLC)
“I just knew the VA would have my best interests at heart” (Veteran, VA CLC)
Their caregivers expressed similar confidence:
“I’m not gonna decide [on whether the patient they care for goes to postacute care], like I told you, that’s totally up to the VA. I have trust and faith in them…so wherever they send him, that’s where he’s going” (Caregiver, VA hospital)
In some cases, this perspective was closer to the halo effect: a positive experience with the care provider or the care team led the decision-makers to believe that their recommendations about postacute care would be similarly positive.
“I think we were very trusting in the sense that whatever happened the last time around, he survived it…they took care of him…he got back home, and he started his life again, you know, so why would we question what they’re telling us to do? (Caregiver, VA hospital)
In contrast to Veterans, non-Veteran patients seemed to experience authority bias when it came to the inpatient team.
“Well, I’d like to know more about the PTs [Physical Therapists] there, but I assume since they were recommended, they will be good.” (Patient, University hospital)
This perspective was especially apparent when it came to physicians:
“The level of trust that they [patients] put in their doctor is gonna outweigh what anyone else would say.” (Clinical liaison, SNF)
“[In response to a question about influences on the decision to go to rehab] I don’t…that’s not my decision to make, that’s the doctor’s decision.” (Patient, University hospital)
“They said so…[the doctor] said I needed to go to rehab, so I guess I do because it’s the doctor’s decision.” (Patient, University hospital)
Default/Status quo Bias
In a related way, patients and caregivers with exposure to a SNF seemed to default to the same SNF with which they had previous experience. This bias seems to be primarily related to knowing what to expect.
“He thinks it’s [a particular SNF] the right place for him now…he was there before and he knew, again, it was the right place for him to be” (Caregiver, VA hospital)
“It’s the only one I’ve ever been in…but they have a lot of activities; you have a lot of freedom, staff was good” (Patient, VA hospital)
“I’ve been [to this SNF] before and I kind of know what the program involves…so it was kind of like going home, not, going home is the wrong way to put it…I mean coming here is like something I know, you know, I didn’t need anybody to explain it to me.” (Patient, VA hospital)
“Anybody that’s been to [SNF], that would be their choice to go back to, and I guess I must’ve liked it that first time because I asked to go back again.” (Patient, University hospital)
Anchoring Bias
While anchoring bias was less frequent, it came up in two domains: first, related to costs of care, and second, related to facility characteristics. Costs came up most frequently for Veterans who preferred to move their care to the VA for cost reasons, which appeared in these cases to overshadow other considerations:
