Optimizing electronic health record prompts with behavioral economics to improve prescribing for older adults

优化电子健康记录促进行为经济学改善老年人处方

• 批准号: 10245079
• 负责人: Niteesh K Choudhry
• 金额: $ 70.15万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-09-15 至 2024-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10245079
• 关键词: Adverse drug event; Adverse event; Alternative Therapies; Anti-Cholinergics; Antipsychotic Agents; Awareness; Benzodiazepines; Caregivers; Clinical; Cluster randomized trial; Confusion; Data; Drops; Drug Prescriptions; Drug usage; Effectiveness; Elderly; Electronic Health Record; Ensure; Environment; Evaluation; Focus Groups; Fracture; Geriatrics; Guidelines; Health; Healthcare Systems; Hospitalization; Imagery; Insurance Carriers; Intervention; Methods; Outcome; Outpatients; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Physicians; Practice Guidelines; Provider; Randomized; Randomized Controlled Trials; Research; Research Design; Risk; Science; Sedation procedure; Structure; System; Techniques; Testing; arm; base; behavior change; behavioral economics; clinical decision-making; clinically significant; design; effectiveness evaluation; effectiveness validation; electronic data; falls; high risk; hypnotic; improved; innovation; insight; multidisciplinary; novel; pressure; primary outcome; provider behavior; randomized trial; secondary outcome; sedative; social norm; success; support tools; tool; treatment as usual; trial design; usability

Prescribing of potentially unsafe medications for older adults is extremely common; benzodiazepines, antipsychotics, anticholinergics, and sedative hypnotics are four key drug classes frequently implicated in adverse health consequences for vulnerable older adults, such as confusion or sedation, leading to hospitalizations, falls, and fractures. Fortunately, most of these consequences are preventable. Physicians’ lack of awareness of alternatives, ambiguous practice guidelines, and perceived pressure from patients or caregivers are among the reasons why these drugs are used more than might be optimal. Reducing inappropriate use of these drugs may be achieved through decision support tools for providers that are embedded in electronic health record (EHR) systems. While EHR strategies are widely used to support the informational needs of providers, these tools have demonstrated only modest effectiveness at improving prescribing. The effectiveness of these tools could be enhanced by leveraging principles of behavioral economics and related sciences. In specific, three behavioral economic principles, such as salience effects, social norming, and default bias, have successfully changed behavior in other settings but have had very limited application in EHRs and, more specifically, for prescribing in older adults. To this end, we propose three cluster randomized controlled trials of novel EHR decision support tools that seek to reduce inappropriate prescribing for these drug classes and their associated adverse drug events and health outcomes. This proposal builds on many years of research by our group on interventions to engage providers and patients in clinical-decision making, behavior change, and evaluating novel interventions in real- world delivery systems. The EHR decision support tools will be designed using promising behavioral economic principles such as salience effects, social norming, and default bias. The specific aims of this study are to: (1) design and pilot test multiple EHR decision support tools constructed using behavioral economics principles; (2) rapidly identify the potential effectiveness of numerous EHR tools at reducing inappropriate prescribing using a novel randomized adaptive design; (3) examine whether these most potentially promising EHR tools from Aim 2 reduce inappropriate prescribing and adverse drug events when using a randomized parallel group trial; and (4) evaluate the effectiveness of the EHR tools in a different clinical environment. Using rigorous randomized designs, we have proposed a pragmatic and scalable approach to optimizing and evaluating EHR tools aimed at provider behavior change for prescribing for older adults. We will also be able to rigorously test a large number of EHR tools as well as replicate and validate the effectiveness of the best performing tools in a different healthcare system. The expected overall impact of this innovative proposal is that it will fundamentally advance how behavioral economics can be used to optimize decision support to reduce inappropriate prescribing and ultimately improve patient outcomes.

为老年人开出潜在不安全药物的处方是非常常见的；苯二氮类药物， 抗精神病药物、抗胆碱能药物和镇静催眠药是经常涉及的四个关键药物类别 对脆弱的老年人的不利健康后果，如精神错乱或镇静，导致 住院、摔倒和骨折。幸运的是，这些后果中的大多数是可以预防的。医生的 缺乏对替代方案的认识，实践指南含糊不清，以及来自患者或 护理者是这些药物使用量超过最佳水平的原因之一。减少 这些药物的不适当使用可能是通过以下提供商的决策支持工具来实现的 嵌入电子健康记录(EHR)系统。虽然电子病历策略被广泛用于支持 为了满足供应商的信息需求，这些工具在改善 开处方。这些工具的有效性可以通过利用行为学原理来提高 经济学及相关科学。具体地说，三个行为经济学原理，如显著效应， 社交规范和默认偏见已经成功地改变了其他环境中的行为，但 在EHR中的应用有限，更具体地说，用于老年人的处方。 为此，我们提出了三个新的电子病历决策支持工具的集群随机对照试验 寻求减少这些药物类别的不适当处方及其相关的不良药物事件，并 健康结果。这项建议建立在我们小组多年来对干预措施进行的研究基础上 提供者和患者在临床决策、行为改变和评估新干预措施方面的实时 全球交付系统。电子病历决策支持工具将使用有前景的行为经济学进行设计 显著效应、社交规范和默认偏见等原则。 本研究的具体目的是：(1)设计和中试多种电子病历决策支持工具 使用行为经济学原理构建；(2)快速识别众多 使用一种新的随机适应性设计的EHR工具减少不适当的处方；(3)检查 这些来自Aim 2的最有潜力的电子病历工具是否减少了不适当的处方和不良反应 使用随机、平行分组试验时的药物事件；以及(4)评估EHR工具的有效性 在不同的临床环境中。使用严格的随机设计，我们提出了一个务实和 一种可扩展的方法，用于优化和评估旨在改变处方提供者行为的电子病历工具 为老年人准备的。我们还将能够严格测试大量的EHR工具，以及复制和 验证最佳性能工具在不同医疗保健系统中的有效性。预期的总体情况 这一创新提议的影响是，它将从根本上推动行为经济学的应用 优化决策支持，以减少不适当的处方，并最终改善患者的预后。

项目成果

Rationale and design of the Novel Uses of adaptive Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) pragmatic adaptive randomized trial: a trial protocol.

• DOI: 10.1186/s13012-020-01078-9
• 发表时间: 2021-01-07
• 期刊: Implementation science : IS
• 作者: Lauffenburger JC;Isaac T;Trippa L;Keller P;Robertson T;Glynn RJ;Sequist TD;Kim DH;Fontanet CP;Castonguay EWB;Haff N;Barlev RA;Mahesri M;Gopalakrishnan C;Choudhry NK
• 通讯作者: Choudhry NK

Designing and conducting adaptive trials to evaluate interventions in health services and implementation research: practical considerations.

设计和进行适应性试验以评估卫生服务干预措施和实施研究：实际考虑。

• DOI: 10.1136/bmjmed-2022-000158
• 发表时间: 2022
• 期刊: BMJ medicine
• 作者: Lauffenburger,JulieC;Choudhry,NiteeshK;Russo,Massimiliano;Glynn,RobertJ;Ventz,Steffen;Trippa,Lorenzo
• 通讯作者: Trippa,Lorenzo