Reducing High Risk Polypharmacy Using Behavioral Economics through Electronic Health Records

项目总结/摘要 高风险的多种药物在美国的老年人中很常见， 如药物不良反应，福尔斯，以及更高的护理费用。认知障碍或痴呆患者 可能特别容易出现多种药物治疗的不良后果。到目前为止，为降低死亡率所作的努力 高风险多种药物治疗由于其每位临床医生的费用和其适度的 有效地帮助临床医生停止潜在的不适当的药物。这些先前的努力依赖于 理性的临床医生行为模式。然而，像一般人一样，临床医生容易受到非理性的影响， 偏见和认知捷径，可能会延续不适当的高风险多药。因此，我们认为， 行为经济学的助推，不假设理性的决策，可能是很好的定位， 减少这种高风险的多药治疗。此外，这种推动可以嵌入电子健康记录中 （EHR），以每位临床医生的低成本提高其可扩展性-只要临床医生可以接受， 担心EHR对他们工作流程的影响。 该项目的总体目标是测试基于EHR的行为经济推动， 降低老年患者中高风险多药治疗的患病率和程度，并描述其 影响临床医生的经验和工作流程。具体目标是（1）评估EHR的效果- 基于承诺的轻推、理由轻推以及两种轻推的组合 在所有老年人和痴呆或轻度认知障碍的亚群中， 通过一项实用的随机对照试验。这将使用分组随机化，其中初级保健诊所 使用析因设计，将来自两个大型卫生系统的患者随机接受0、1或2次轻推。的 推动将运行18个月，然后进行12个月的观察，以评估效果的持续性;以及（2） 定性和定量地评估临床医生对基于EHR的轻推的经验，包括他们的 可接受性和对工作流程的影响。在干预期结束时，半结构化访谈 大约40名临床医生将被用来详细描述他们的经验与轻推， 将进行临床医生调查以检查临床医生对轻推的感知之间的关系， 他们对EHR工具的实际使用，以及这些因素与高风险的实际变化的关系 多药疗法这项研究将产生基于EHR的推动，可以在全国范围内实施，详细 描述这些推动如何影响临床医生的工作流程（以刺激传播），以及科学论文 记录了助推在减少老年人中高风险多种药物使用方面的有效性。

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.