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
“I kept emphasizing that the VA could do all the same things at a lot more reasonable price. The whole purpose of having the VA is for the Veteran, so that…we can get the healthcare that we need at a more reasonable [sic] or a reasonable price.” (Veteran, CLC)
“I think the CLC [VA SNF] is going to take care of her probably the same way any other facility of its type would, unless she were in a private facility, but you know, that costs a lot more money.” (Caregiver, VA hospital)
Patients occasionally had striking responses to particular characteristics of SNFs, regardless of whether this was a central feature or related to their rehabilitation:
“The social worker comes and talks to me about the nursing home where cats are running around, you know, to infect my leg or spin their little cat hairs into my lungs and make my asthma worse…I’m going to have to beg the nurses or the aides or the family or somebody to clean the cat…” (Veteran, VA hospital)
Framing
Framing was the strongest theme among clinician interviews in our sample. Clinicians most frequently described the SNF as a place where patients could recover function (a positive frame), explaining risks (eg, rehospitalization) associated with alternative postacute care options besides the SNF in great detail.
“Aside from explaining the benefits of going and…having that 24-hour care, having the therapies provided to them [the patients], talking about them getting stronger, phrasing it in such a way that patients sometimes are more agreeable, like not calling it a skilled nursing facility, calling it a rehab you know, for them to get physically stronger so they can be the most independent that they can once they do go home, and also explaining … we think that this would be the best plan to prevent them from coming back to the hospital, so those are some of the things that we’ll mention to patients to try and educate them and get them to be agreeable for placement.” (Social worker, University hospital)
Clinicians avoided negative associations with “nursing home” (even though all SNFs are nursing homes) and tended to use more positive frames such as “rehabilitation facility.”
“Use the word rehab….we definitely use the word rehab, to get more therapy, to go home; it’s not a, we really emphasize it’s not a nursing home, it’s not to go to stay forever.” (Physical therapist, safety-net hospital)
Clinicians used a frame of “safety” when discussing the SNF and used a frame of “risk” when discussing alternative postacute care options such as returning home. We did not find examples of clinicians discussing similar risks in going to a SNF even for risks, such as falling, which exist in both settings.
“I’ve talked to them primarily on an avenue of safety because I think people want and they value independence, they value making sure they can get home, but you know, a lot of the times they understand safety is, it can be a concern and outlining that our goal is to make sure that they’re safe and they stay home, and I tend to broach the subject saying that our therapists believe that they might not be safe at home in the moment, but they have potential goals to be safe later on if we continue therapy. I really highlight safety being the major driver of our discussion.” (Physician, VA hospital)
