Reducing High Risk Polypharmacy Using Behavioral Economics through Electronic Health Records

通过电子健康记录利用行为经济学减少高风险的多重用药

• 批准号: 10441966
• 负责人: Stephen Persell
• 金额: $ 53.86万
• 依托单位: NORTHWESTERN UNIVERSITY AT CHICAGO
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-08-01 至 2026-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10441966
• 关键词: Academic Detailing; Adult; Adverse drug event; Affect; Antibiotics; Beer; Caring; Clinic; Clinical; Clinical Pharmacists; Cognitive; Combination Medication; Country; County; Dangerousness; Data; Decision Making; Dementia; Drug Interactions; Education; Effectiveness; Elderly; Electronic Health Record; Environment; Event; Feeling; Funding; Future; Health system; Impaired cognition; Individual; Intervention; Interview; Logic; Measures; Medical; Medicare; Methods; Modeling; Paper; Patients; Perception; Persons; Pharmaceutical Preparations; Physicians; Polypharmacy; Positioning Attribute; Pragmatic clinical trial; Prevalence; Prevention; Primary Care Physician; Primary Health Care; Public Health Informatics; Randomized; Randomized Controlled Trials; Reporting; Research; Risk; Running; Rural; Screening procedure; Site; Social Accountability; Specific qualifier value; Structure; Subgroup; Surveys; System; Techniques; Testing; Thinking; Time; United States; United States National Institutes of Health; Weight; adverse drug reaction; adverse outcome; base; behavioral economics; beneficiary; care costs; cost; design; discount; experience; falls; health plan; high risk; human old age (65+); improved; medication nonadherence; medication safety; mild cognitive impairment; mortality; multidisciplinary; overtreatment; pilot test; prescription opioid; provider behavior; suburb; tool; uptake

Project Summary/Abstract High-risk polypharmacy is common among older adults in the United States and is associated with harms such as adverse drug reactions, falls, and higher costs of care. Individuals with cognitive impairment or dementia may be at particularly at risk for adverse outcomes from polypharmacy. To date, efforts to reduce the rate of high-risk polypharmacy have had limited uptake due to their expense per clinician and their modest effectiveness in helping clinicians stop potentially inappropriate medications. These prior efforts have relied on rational clinician behavior models. However, like people in general, clinicians are susceptible to irrational biases and cognitive shortcuts that might perpetuate inappropriate high-risk polypharmacy. Therefore, behavioral economic nudges, which do not assume rational decision making, might be well-positioned to reduce such high-risk polypharmacy. Moreover, such nudges can be embedded in electronic health records (EHRs), enhancing their scalability at a low cost per clinician—as long as they are acceptable to clinicians who worry about EHRs’ effects on their workflows. The overall objectives of the project are to test EHR-based behavioral economic nudges that may reduce the prevalence and degree of high-risk polypharmacy among older adult patients and to describe their impact on clinicians’ experiences and workflows. The specific aims are (1) to evaluate the effects of an EHR- based commitment nudge, a justification nudge, and the combination of both nudges on a composite measure of high-risk polypharmacy in all older adults and the subpopulation with dementia or mild cognitive impairment via a pragmatic randomized controlled trial. This will use cluster randomization in which primary care clinics from two large health systems are randomized to receive 0, 1, or 2 nudges using a factorial design. The nudges will run for 18 months, followed by 12 months of observation to assess persistence of effects; and (2) to assess qualitatively and quantitatively clinician experiences with the EHR-based nudges, including their acceptability and effects on workflow. At the conclusion of the intervention period, semi-structured interviews with approximately 40 clinicians will be used to describe their experiences with the nudges in detail, and a clinician survey will be conducted to examine the relationships between clinicians’ perceptions of the nudges, their actual use of the EHR tools, and the relationships of these factors to actual changes in high-risk polypharmacy. The study will yield EHR-based nudges that can be implemented across the country, detailed descriptions of how these nudges affect clinicians’ workflows (to spur dissemination), and scientific papers documenting the nudges’ effectiveness in reducing high-risk polypharmacy among older adults.

项目概要/摘要 高风险的多重用药在美国老年人中很常见，并与以下危害相关： 如药物不良反应、跌倒和更高的护理费用。患有认知障碍或痴呆症的人 可能特别面临多重用药不良后果的风险。迄今为止，为降低发生率所做的努力 由于每位临床医生的费用及其适度，高风险的复合用药的采用率有限。 帮助临床医生停止可能不适当的药物的有效性。这些先前的努力依赖于 理性的临床医生行为模型。然而，像一般人一样，临床医生也容易受到非理性的影响。 偏见和认知捷径可能会导致不适当的高风险多重用药长期存在。所以， 不假设理性决策的行为经济推动可能很适合 减少这种高风险的多重用药。此外，这种推动可以嵌入电子健康记录中 （EHR），以每个临床医生的低成本增强其可扩展性——只要它们能为以下临床医生所接受： 担心电子病历对其工作流程的影响。 该项目的总体目标是测试基于电子病历的行为经济推动力，这些推动力可能 降低老年患者高风险多重用药的患病率和程度，并描述他们的情况 对临床医生的经验和工作流程的影响。具体目标是 (1) 评估 EHR 的效果 基于承诺的推动、理由推动以及两种推动在综合措施上的结合 所有老年人和患有痴呆或轻度认知障碍的亚人群中高风险的多药治疗 通过务实的随机对照试验。这将使用整群随机化，其中初级保健诊所 使用析因设计，来自两个大型卫生系统的患者被随机接受 0、1 或 2 次微调。这 推动将持续 18 个月，随后进行 12 个月的观察以评估效果的持久性；和（2） 定性和定量评估临床医生使用基于电子病历的推动的经验，包括他们的经验 可接受性和对工作流程的影响。干预期结束时，进行半结构化访谈 大约 40 名临床医生将详细描述他们在推动方面的经验，并且 将进行临床医生调查，以检查临床医生对推动的看法之间的关系， 他们对 EHR 工具的实际使用，以及这些因素与高风险实际变化的关系 多药治疗。该研究将产生基于电子病历的推动，可以在全国范围内实施，详细说明 关于这些推动如何影响临床医生的工作流程（以促进传播）的描述以及科学论文 记录这些推动措施在减少老年人高风险多重用药方面的有效性。