Leveraging Electronic Health Records to Measure and Reduce Harmful, Low-Value Care Among Older Adults

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ABSTRACT I (John N. Mafi, MD, MPH) am an Assistant Professor at UCLA, with a secondary Natural Scientist appointment at RAND. I practice general internal medicine and pursue health services research focused on identifying and reducing low-value care—patient care that provides no net benefit in specific clinical scenarios, and can also cause harm. After receiving outstanding training in health services research at Harvard University and publishing a series of papers on low-value care, I have turned the focus of my research on studying older adults because they disproportionately suffer from low-value care and its consequences. A major barrier to reducing low-value care in older adults is a lack of valid measures: current measurement relies on claims data (e.g., billing claims physicians submit to Medicare) that lack enough clinical detail to correctly classify care as “low value.” In contrast, electronic health records (EHRs) contain richer clinical data and are also a potential tool for reducing low-value care. To advance my career goals and improve care for older adults, I propose to develop an EHR-based low-value care measure (“eMeasure”), and then design and test an intervention consisting of a behavioral economic EHR clinical decision support tool (EHR CDS) to reduce low-value care in older adults. My prototype focus will address low-value proton pump inhibitor (PPI) drugs, which are associated with some harm. My overarching goal is to improve the health and healthcare of older Americans by becoming a leading principal investigator utilizing the EHR to measure and reduce low-value care in older adults. To achieve this goal, I seek support from the NIA Beeson Career Development Award. I have the support of an outstanding group including primary mentor Dr. Catherine Sarkisian (Professor, PI of NIA-R01 pragmatic trial), co-primary mentor Dr. Cheryl Damberg (PI of RAND/AHRQ U19 Center), mentors Dr. Ron Hays (Quality Measure Expert), Dr. Eric Cheng (Chief Medical Informatics Officer), Dr. Noah Goldstein (Economist), and collaborators Dr. Folasade May (Gastroenterologist), Dr. Sam Skootsky (Chief Medical Officer), and Dr. Chi- Hong Tseng (Statistician). I will acquire skills in EHR-based quality measure development and utilization (Damberg/Hays/Cheng), geriatrics (Sarkisian), behavioral economics and behavior change (Goldstein), pragmatic trials testing user-centered EHR decision support (Sarkisian/Damberg/Cheng), and leadership. I propose 3 specific aims for my career development: (1) Develop and test an eMeasure of low-value PPI prescriptions among older adults, (2) Design and pilot test an intervention (behavioral economic EHR CDS) to reduce low-value PPI prescriptions in older adults to determine feasibility and (3) Implement and evaluate a delayed-onset pragmatic trial of the intervention at UCLA Health—informing an NIA R01 proposal for a multisite pragmatic trial. I will apply knowledge learned from my training to Aims #1-3. The Beeson Award would provide me with the training and skills needed to become a national leader and independent clinician scientist utilizing the EHR to rigorously measure and reduce harmful, low-value care among older Americans.