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的药物是极为普遍的。苯二氮卓类药物， 抗精神病药，抗胆碱能和镇静催眠药是经常实施的四个关键药物类别 对脆弱的老年人（例如混乱或镇静）造成的不利健康后果，导致 住院，跌倒和骨折。幸运的是，这些后果大多数是可以预防的。医生的 缺乏对替代方案的认识，模棱两可的实践指南以及患者的感知压力或 护理人员是使用这些药物多于最佳的原因之一。减少 可以通过为提供者的决策支持工具来实现这些药物的不当使用 嵌入电子健康记录（EHR）系统中。 EHR策略被广泛用于支持 提供商的信息需求，这些工具仅证明了改善的适度有效性 处方。通过利用行为原则，可以增强这些工具的有效性 经济学和相关科学。在特定的三种行为经济原则（例如显着效应）中， 社会规范和违约偏见已成功改变了其他环境的行为，但有非常 在EHR中的应用有限，更具体地说是在老年人中处方。 为此，我们提出了新的EHR决策支持工具的三个集群随机对照试验， 寻求减少这些药物类及其相关的不良药物事件的不适当处方，以及 健康结果。这项提案是在我们小组多年来研究干预措施的多年研究的基础上建立的 提供者和患者在临床决策，改变行为以及评估新型干预措施中 世界交付系统。 EHR决策支持工具将使用有希望的行为经济设计 诸如显着效应，社会规范和默认偏见之类的原则。 这项研究的具体目的是：（1）设计和试点测试多重EHR决策支持工具 使用行为经济学原则建造； （2）迅速确定众多的潜在有效性 EHR工具使用新颖的随机自适应设计来减少不适当的处方； （3）检查 这些最有可能来自AIM 2的最有前途的EHR工具减少了不适当的开处方和敌对 使用随机平行组试验时的药物事件； （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，我们提出了务实的 优化和评估EHR工具的可扩展方法，旨在规定提供商行为的行为更改 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最佳性能工具的有效性。总体预期 这项创新提议的影响是，它将从根本上推进如何使用行为经济学 优化决策支持以减少不适当的处方并最终改善患者的结果。

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