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.

为老年人开具潜在不安全药物的情况极为常见；苯二氮卓类药物， 抗精神病药、抗胆碱能药和镇静催眠药是常见的四种主要药物类别 对脆弱的老年人造成不利的健康后果，例如混乱或镇静，导致 住院、跌倒和骨折。幸运的是，大多数这些后果是可以预防的。医生的 缺乏对替代方案的认识、模棱两可的实践指南以及来自患者或患者的压力 护理人员是这些药物使用量超过最佳用量的原因之一。减少 这些药物的不当使用可以通过为提供者提供的决策支持工具来实现，这些工具是 嵌入电子健康记录（EHR）系统中。虽然 EHR 策略被广泛用于支持 供应商的信息需求，这些工具在改善 开处方。通过利用行为原则可以提高这些工具的有效性 经济学及相关科学。具体来说，三个行为经济学原理，例如显着效应， 社会规范和默认偏见已经成功地改变了其他环境中的行为，但也产生了很大的影响。 在电子病历中的应用有限，更具体地说，在老年人处方中的应用有限。 为此，我们提出了三项新型 EHR 决策支持工具的集群随机对照试验， 寻求减少对这些药物类别的不当处方及其相关的药物不良事件， 健康结果。该提案建立在我们小组多年关于干预措施的研究基础上 提供者和患者进行临床决策、行为改变以及评估真实的新干预措施 世界运输系统。 EHR 决策支持工具将使用有前途的行为经济学来设计 显着效应、社会规范和默认偏见等原则。 本研究的具体目标是：（1）设计并试点测试多种 EHR 决策支持工具 使用行为经济学原理构建； (2) 快速识别众多潜在的有效性 使用新颖的随机自适应设计减少不当处方的 EHR 工具； (3)检查 目标 2 中这些最有潜力的 EHR 工具是否可以减少不当处方和不良处方 使用随机平行组试验时发生的药物事件； (4) 评估 EHR 工具的有效性 在不同的临床环境中。通过严格的随机设计，我们提出了一种务实且 优化和评估 EHR 工具的可扩展方法，旨在改变提供者的处方行为 对于老年人。我们还将能够严格测试大量 EHR 工具以及复制和 验证不同医疗保健系统中性能最佳的工具的有效性。预期整体 这一创新提案的影响在于，它将从根本上推进行为经济学的应用 优化决策支持，减少不当处方，最终改善患者治疗效果。

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