Using Nudges to Implement Comparative Effectiveness: Behavioral Economics and Sta

行为经济学代表了一种强大的，但未充分利用的工具，通过这种工具可以大规模，有意义和可持续的方式影响供应商和系统的行为。我们建议使用一个复杂的电子健康记录（EHR）系统，改变医生的默认选择，最支持的临床实践指南（CPG）的选择。我们在一个临床领域选择了两种类型的医生行为：为心脏风险升高和低密度脂蛋白胆固醇（LDL-C）升高的患者开具HMG-CoA还原酶抑制剂（他汀类药物），以及滴定他汀类药物剂量以达到LDL-C目标，两者均符合胆固醇管理指南。在一个私人的，以社区为基础的多专业实践的集群随机试验中，我们建议将常规护理与自动化，默认，选择退出的临床决策支持系统进行比较，该系统可以酌情处方和替泊他汀类药物。 公共卫生相关性：目前有多个指南描述了有效干预的最佳实践，但实际和最佳指南合规性之间存在很大差距。这项拟议的研究将检查选择退出药物管理协议相对于常规护理的患者不符合目标的比较有效性，使用国家胆固醇管理指南，该指南在一个大型多专业私人诊所中实施，该诊所使用电子健康记录系统。

DESCRIPTION (provided by applicant): Behavioral economics represents a powerful, albeit underutilized tool by which to influence provider and systems behavior in a large-scale, meaningful, and sustainable way. We propose to use a sophisticated electronic health record (EHR) system to change the default choice for physicians to the choice most supported by clinical practice guidelines (CPG). We have selected two types of physician behaviors in one clinical area: prescribing HMG-CoA reductase inhibitors (statins) to patients with elevated cardiac risk and elevated low density lipoprotein cholesterol (LDL-C), and titrating statin dose to achieve LDL-C goals, both in step with cholesterol management guidelines. In a cluster randomized trial in a private, community-based multispecialty practice, we propose to compare usual care to a system of automated, default, opt-out clinical decision support that prescribes and titrates statins as appropriate. PUBLIC HEALTH RELEVANCE: Multiple guidelines exist describing best practices for effective interventions, yet a large gap persists between actual and optimal guideline compliance. The proposed study will examine the comparative effectiveness of an opt-out medication management protocol relative to usual care for patients not at goal, using national guidelines for cholesterol management implemented in a large multispecialty private practice that uses an Electronic Health Record system.