Scott Halpern

University of Pennsylvania | UP · Department of Medicine

Background Though European Respiratory Society and American Thoracic Society (ERS/ATS)guidelines for pulmonary function test (PFT) interpretation recommend the use of the forced vital capacity (FVC) lower limit of normal (LLN) to exclude restriction, recent data suggest that the negative predictive value (NPV) of the FVC LLN is lower than has been...

We sought to understand how persons living with dementia (PWD) and their family care partners value hypothetical treatment outcomes relative to one other using a point allocation task. Participants distributed 100 points across six potential outcomes based on perceived relative importance. Outcomes included slowed decline in brain function, reduced...

Background European Respiratory Society and American Thoracic Society (ERS/ATS) guidelines for pulmonary function test (PFT) interpretation recommend the use of a normal forced vital capacity (FVC) to exclude restriction. However, this recommendation is based upon a single study from 1999, which was limited to White patients, and used race-specific...

Background Promoting options for aging in place (AIP) has broad appeal to policymakers and professionals providing services to persons living with dementia (PWD). However, the benefits or burdens of AIP likely vary among individuals and families. We sought to describe factors influencing decision‐making to age in place versus seek a higher level of...

Background In the US, 1.2 million people live with HIV (PWH). Despite having near-normal life expectancies due to antiretroviral therapy (ART), many PWH seek an HIV cure, even if it means risking their lives. This willingness to take risks for a cure raises questions about “affective forecasting biases,” where people tend to overestimate the positi...

Background Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the diagnosis of chronic obstructive pulmonary disease (COPD) only in patients with a post-bronchodilator forced expiratory volume in 1 second to forced vital capacity ratio (FEV1/FVC) less than 0.7. However the impact of this recommendation on clinical pr...

Distracted driving is responsible for nearly 1 million crashes each year in the United States alone, and a major source of driver distraction is handheld phone use. We conducted a randomized, controlled trial to compare the effectiveness of interventions designed to create sustained reductions in handheld use while driving (NCT04587609). Participan...

Background Women are more likely than men to report delays in the diagnosis of chronic obstructive pulmonary disease (COPD), though the etiology of these delays is unknown. We sought to test whether delays in COPD diagnosis persist after the performance of spirometry. Methods We used the Optum Labs Data Warehouse to identify patients 18 years of a...

Importance Handheld phone use while driving is a major factor in vehicle crashes. Scalable interventions are needed to encourage drivers not to use their phones. Objective To test whether interventions involving social comparison feedback and/or financial incentives can reduce drivers’ handheld phone use. Design, Setting, and Participants In a ra...

Estimands can help clarify the interpretation of treatment effects and ensure that estimators are aligned with the study's objectives. Cluster-randomised trials require additional attributes to be defined within the estimand compared to individually randomised trials, including whether treatment effects are marginal or cluster-specific, and whether...

Treatment decisions for patients receiving invasive mechanical ventilation (IMV) are complex and depend simultaneously on the current ventilator settings, the function of multiple interrelated organ systems, and other treatments. An artificial intelligence (AI)-based clinical decision support system (CDSS) offers a promising approach to alleviate u...

Background The ability to classify patients’ goals of care (GOC) from clinical documentation would facilitate serious illness communication quality improvement efforts and pragmatic measurement of goal-concordant care. Feasibility of this approach remains unknown. Objective To evaluate the feasibility of classifying patients’ GOC from clinical doc...

Understanding whether and how treatment effects vary across subgroups is crucial to inform clinical practice and recommendations. Accordingly, the assessment of heterogeneous treatment effects based on pre-specified potential effect modifiers has become a common goal in modern randomized trials. However, when one or more potential effect modifiers...

Rationale: Hospital-free days (HFDs), a measure of the number of days alive spent outside the hospital, is increasingly used as an endpoint in studies of patients with acute respiratory failure (ARF) or other critical and serious illnesses. Current approaches to measuring HFDs do not account for decrements in functional status or quality of life th...

Importance Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking. Objective To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and impro...

Background “Aging in place” (AIP), the ability to remain in one’s home with age, has broad appeal to policy makers and professionals providing services to adults with serious illness. AIP is viewed as both an intervention for people with dementia (PWD) and as a desirable outcome. However, it’s not clear that AIP is always associated with sustained...

Background Composite measures of survival and residence, such as institution‐free days (IFDs), encompass many patient and family priorities and are readily measured using payer claims or electronic health record data. However, knowledge gaps limit their application to studies of people with dementia (PWD). First, PWD, family care partners, and clin...

Objective To investigate how missing data in the patient problem list may impact racial disparities in the predictive performance of a machine learning (ML) model for emergency department (ED) triage. Materials and Methods Racial disparities may exist in the missingness of EHR data (eg, systematic differences in access, testing, and/or treatment)...

Importance Patients’ expectations for future health guide their decisions and enable them to prepare, adapt, and cope. However, little is known about how inaccurate expectations may affect patients’ illness outcomes. Objective To assess the association between patients’ expectation inaccuracies and health-related quality of life. Design, Setting,...

In many medical studies, the outcome measure (such as quality of life, QOL) for some study participants becomes informatively truncated (censored, missing, or unobserved) due to death or other forms of dropout, creating a nonignorable missing data problem. In such cases, the use of a composite outcome or imputation methods that fill in unmeasurable...

ChatGPT is a large language model trained on text corpora and reinforced with human supervision. Because ChatGPT can provide human-like responses to complex questions, it could become an easily accessible source of medical advice for patients. However, its ability to answer medical questions appropriately and equitably remains unknown. We presented...

Introduction: Analyzing hospital-free days (HFDs) offers a patient-centered approach to health services research. We hypothesized that, within emergency general surgery (EGS), multimorbidity would be associated with fewer HFDs, whether patients were managed operatively or nonoperatively. Methods: EGS patients were identified using national Medic...

Supply–demand mismatch of ward resources (“ward capacity strain”) alters care and outcomes. Narrow strain definitions and heterogeneous populations limit strain literature. Evaluate the predictive utility of a large set of candidate strain variables for in-hospital mortality and discharge destination among acute respiratory failure (ARF) survivors....

Importance: Race and ethnicity are routinely used to inform pulmonary function test (PFT) interpretation. However, there is no biological justification for such use, and it may reinforce health disparities. Objective: To compare the PFT interpretations produced with race-neutral and race-specific equations. Design, setting, and participants: I...

This survey study examined perceptions of patients, caregivers and health care professionals on the number of hospital-free days required for detection of a minimum clinically important difference or noninferiority margin of new interventions.

Objective: To understand how multimorbidity impacts operative versus non-operative management of Emergency General Surgery conditions. Background: Emergency General Surgery (EGS) is a heterogenous field, encompassing operative and non-operative treatment options. Decision-making is particularly complex for older patients with multimorbidity. Me...

Importance: Although racial and ethnic minority patients with sepsis and acute respiratory failure (ARF) experience worse outcomes, how patient presentation characteristics, processes of care, and hospital resource delivery are associated with outcomes is not well understood. Objective: To measure disparities in hospital length of stay (LOS) amo...

Objective: Evaluate predictive performance of an electronic health record (EHR)-based, inpatient 6-month mortality risk model developed to trigger palliative care consultation among patient groups stratified by age, race, ethnicity, insurance and socioeconomic status (SES), which may vary due to social forces (eg, racism) that shape health, health...

Rationale: Small trials and professional recommendations support mobilization interventions to improve recovery among critically ill patients, but their real-world effectiveness is unknown. Objective: To evaluate a low-cost, multifaceted mobilization intervention. Methods: We conducted a stepped-wedge cluster-randomized trial across 12 ICUs with di...

Estimands can help clarify the interpretation of treatment effects and ensure that estimators are aligned to the study's objectives. Cluster randomised trials require additional attributes to be defined within the estimand compared to individually randomised trials, including whether treatment effects are marginal or cluster specific, and whether t...

ChatGPT is a large language model trained on text corpora and reinforced with human supervision. Because ChatGPT can provide human-like responses to complex questions, it could become an easily accessible source of medical advice for patients. However, its ability to answer medical questions appropriately and equitably remains unknown. We presented...

Unlabelled: To understand how strain-process-outcome relationships in patients with sepsis may vary among hospitals. Design: Retrospective cohort study using a validated hospital capacity strain index as a within-hospital instrumental variable governing ICU versus ward admission, stratified by hospital. Setting: Twenty-seven U.S. hospitals fro...

Background: Mortality prediction for intensive care unit (ICU) patients frequently relies on single acuity measures based on ICU admission physiology without accounting for subsequent clinical changes. Objectives: Evaluate novel models incorporating modified admission and daily, time-updating Laboratory-based Acute Physiology Scores, version 2 (LAP...

Investigators commonly offer payments to research participants to promote recruitment and retention. Yet the ethics of offering monetary incentives to research participants continues to be debated. Prior conceptual work has addressed some of these concerns; there is, however, also a need for empirical evidence to understand the effects of payment o...

Background: Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. Study design: Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were cl...

Understanding whether and how treatment effects vary across individuals is crucial to inform clinical practice and recommendations. Accordingly, the assessment of heterogeneous treatment effects (HTE) based on pre-specified potential effect modifiers has become a common goal in modern randomized trials. However, when one or more potential effect mo...

Rationale: We have previously shown that hospital strain is associated with ICU admission and that ICU admission, compared to ward admission, may benefit certain patients with acute respiratory failure (ARF). Objective: To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practic...

Rationale: Patients who identify as from racial or ethnic minority groups who have sepsis or acute respiratory failure (ARF) experience worse outcomes relative to nonminority patients, but processes of care accounting for disparities are not well-characterized. Objective: Determine whether reductions in intensive care unit (ICU) admission during...

Background Sacubitril/valsartan improves health outcomes for heart failure with reduced ejection fraction relative to angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, but it carries higher out‐of‐pocket costs. Neither the impact of cost nor how to integrate cost into medical decisions is well studied. Methods and Results...

Outcomes 1. Describe a method to identify and classify patients’ goals of care (GOCs) from documented conversations in the electronic health record (EHR) 2. Understand the general trend of change in GOCs toward comfort-focused care for a cohort of seriously ill inpatients Importance Previous studies assessing patients’ goals of care (GOCs) have be...

Background: Little is known about the impact of multimorbidity on outcomes for older emergency general surgery patients. Objective: The aim was to understand whether having multiple comorbidities confers the same amount of risk as specific combinations of comorbidities (multimorbidity) for a patient undergoing emergency general surgery. Researc...

This research explores the perspectives of seriously ill patients on the completion of documentation and the implementation of advance directives and advance care planning.

Rationale: Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared to those with community-acquired sepsis (CAS). Capacity strain, the extent to which demand for hospital resources exceeds availability thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not...

Background Seriously ill patients rate several health outcomes as states worse than death. It is unclear what factors underlie such valuations, and whether consideration of such states is useful when making medical decisions. Aim We sought to (1) use qualitative approaches to identify states worse than death, (2) identify attributes common to such...

Rationale: Many decisions to admit patients to the ICU are not grounded in evidence regarding who benefits from such triage, straining ICU capacity and limiting its cost-effectiveness. Objectives: To measure the benefits of ICU admission for patients with sepsis or acute respiratory failure. Methods: At 27 U.S. hospitals across two health syst...

Objective Frailty is a prevalent risk factor for adverse outcomes among patients with chronic lung disease. However, identifying frail patients who may benefit from interventions is challenging using standard data sources. We therefore sought to identify phrases in clinical notes in the electronic health record (EHR) that describe actionable frailt...

In a recent study, identifying and supporting patients’ care goals was named the highest priority in hospital medicine. Although sepsis is one of the leading causes of death and postdischarge morbidity among hospitalized patients, little is known about how frequently care goals are assessed prior to discharge and adhered to in the 90 days after sep...

Background: Abdominal pain is the most common chief complaint in US emergency departments (EDs) among patients over 65, who are at high risk of mortality or incident disability after the ED encounter. We sought to characterize the evaluation, management, and disposition of older adults who present to the ED with abdominal pain. Methods: We perfo...

Importance Incentivizing research participation is controversial and variably regulated because of uncertainty regarding whether financial incentives serve as undue inducements by diminishing peoples’ sensitivity to research risks or unjust inducements by preferentially increasing enrollment among underserved individuals. Objective To determine wh...

Background Despite recommendations to integrate palliative care (PC) into care for critically ill trauma patients, little is known about current PC practices in trauma care to inform opportunities for improvement. Objective Describe patterns of PC delivery among a large, critically ill trauma cohort. Setting/Subjects Retrospective cohort study of...

Smoking burdens are greatest among underserved patients. Lung cancer screening (LCS) reduces mortality among individuals at risk for smoking-associated lung cancer. Although LCS programs must offer smoking cessation support, the interventions that best promote cessation among underserved patients in this setting are unknown. This stakeholder-engage...

Background Behavioral economic insights have yielded strategies to overcome implementation barriers. For example, default strategies and accountable justification strategies have improved adherence to best practices in clinical settings. Embedding such strategies in the electronic health record (EHR) holds promise for simple and scalable approaches...

Hospital-free days (HFDs), alternatively known as "days alive and outside the hospital," is increasingly used as a primary or secondary outcome in randomized trials among critically and seriously ill patients. This novel outcome measure addresses an existing gap in the availability of patient-centered, reliably obtained outcome measures among patie...

Background. Presenting numeric data alone may result in patients underappreciating clinically significant benefits. Contextualizing statements to counter this may raise concern about absence of neutrality. These issues arose during construction of a decision aid for sacubitril-valsartan, a heart failure medication associated with a ∼3% absolute red...

Background Sepsis survivors experience high morbidity and mortality, and healthcare systems lack effective strategies to address patient needs after hospital discharge. The Sepsis Transition and Recovery (STAR) program is a navigator-led, telehealth-based multicomponent strategy to provide proactive care coordination and monitoring of high-risk pat...

Rationale: A trial of four financial-incentive programs, conducted at CVS Caremark, a large employer, documented their effectiveness in promoting sustained abstinence from smoking, but their cost-effectiveness is unknown and the significant up-front cost of the incentives is a deterrent to their adoption. Objectives: To determine the cost-effect...

The past decade has witnessed a dramatic expansion in the number of randomized clinical trials (RCTs) testing palliative and other supportive care interventions, including methods to improve advance care planning, specialist and generalist palliative care delivery, and caregiver and clinician decision-making for patients with serious illnesses. How...

Background Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions. Methods In this national study, we conducted semi-structured...

Importance Hospitalization is associated with decreased mobility and functional decline. Behaviorally designed gamification can increase mobility in community settings but has not been tested among patients at risk for functional decline during a high-risk transition period after hospitalization. Objective To test a behaviorally designed gamificat...

Rationale: Crisis standards of care guide critical care resource allocation during crises. Most recommend ranking patients based on their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or other acuity scores perform among patients of different races. Objective: To test the pr...

Background: We sought to identify factors that influence surrogate decision makers' decisions to enroll patients into a critical care randomized controlled trial. Methods: We conducted a qualitative study embedded within a randomized controlled trial testing the effect of a behavioral nudge intervention for surrogate decision makers on enrollmen...

Introduction Predialysis education for patients with advanced chronic kidney disease (CKD) typically focuses narrowly on haemodialysis and peritoneal dialysis as future treatment options. However, patients who are older or seriously ill may not want to pursue dialysis and/or may not benefit from this treatment. Conservative kidney management, a rea...

Background Clinicians’ use of choice architecture, or how they present options, systematically influences the choices made by patients and their surrogate decision makers. However, clinicians may incompletely understand this influence. Objective To assess physicians’ abilities to predict how common choice frames influence people’s choices. Method...

Background Despite increased emphasis on providing higher-quality patient- and family-centered care in the intensive care unit (ICU), there are no widely accepted definitions of such care in the ICU. Objectives To determine (1) aspects of care that patients and families valued during their ICU encounter, (2) outcomes that patients and families pri...

The NIA Edward R. Roybal Centers for Translational Research in the Behavioral and Social Sciences of Aging aim to translate and integrate basic behavioral and social research findings into principle-driven interventions aimed at innovatively improving both the lives of older people and the capacity of institutions to adapt to societal aging. Newly...

The COVID-19 pandemic poses distinct challenges for the conduct of minimal-risk clinical research, including the very definition of minimal risk, the heterogeneity of risk among potential study participants, privacy concerns, and practical issues in recruitment and written informed consent.

Introduction In a five-arm randomized clinical trial (RCT) with stratified randomization across 54 sites, we encountered low primary outcome event proportions, resulting in multiple sites with zero events either overall or in one or more study arms. In this paper, we systematically evaluated different statistical methods of accounting for center in...

Experience with his 103-year-old grandfather teaches a physician-bioethicist that for people without terminal or mental illness who desire to end their life, the alternative to physician-assisted dying — to stop eating and drinking — is just too challenging.

Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The Prognosticating Outcomes and Nudging Decisions with Electronic Re...