Preliminary Implementation of an Informational Nudge to Improve Heart Failure Prescribing

背景：VA在促进指南一致性心力衰竭的策略方面有经验 (HF)但需要更大的创新。轻推理论是一个行为学领域 科学，侧重于决策心理学，并提供了一个新的解决方案，以提高 保健在这项拟议的研究中，我们将评估两个轻推干预，警报和同行 比较反馈，利用构成理论基础的几个偏差 支持行为改变。 重要性：HF治疗差距是严重的，昂贵的，而且太常见了（低采用率）。 SGLT 2 i和MRA）。VA的HF指南导向治疗率停滞不前。我们 研究小组和其他人报告说，34,000和21,000人的死亡可以避免最佳的 在美国分别实施SGLT 2 i和MRA。 创新和影响：我们将测试多成分推动战略的有效性 （警报+同行比较），与单一组成部分战略相比，很少进行这种比较。 在文献中，只有10%的临床导向的推动干预是多成分的， 在VA中没有发现任何人。本研究将创造关于如何将这些联合收割机 进一步推进该领域并有效分配VA所需的不同策略 资源本研究的目标是HF治疗间隙（SGLT 2和MRA），在此间隙中， 研究已经证明了有效性。该提案利用了一种实施科学 (CDS/PRISM）的方法来制定推动战略， 有效性、实施和可持续性。 具体目标： 1)进行形成性评估以制定两种推动策略、信息警报和 同行比较反馈，以鼓励临床医生处方MRA和SGLT 2抑制剂。 2)使用RE-AIM框架评估两种推动策略的初步结果。 a）评估预警和同行比较战略的初步有效性， 四组设计 B）评价两项推动战略的实施成果。 i）我们将报告以下PRISM/RE-AIM结果：干预，接受者， 外部环境、基础设施、覆盖率、采用率和实施率。 方法：这是一项单中心初步研究。对于目标1，我们将开展关键利益相关者 临床医生访谈和焦点小组，以评估SGLT 2和MRA的障碍和促进因素 规定和完善原型推动。对于目标2，临床医生将被随机分配到一个 四个武器：常规护理，信息警报，同行比较反馈，并结合 警报和对等比较。我们将比较有效性，定义为新处方， 三个干预组与对照组在30天内的SGLT 2或MRA。我们还将 报告其他成果，包括安全性、覆盖范围、采用和实施。 下一步/实施：我们将计划在更广泛的试验中测试推动策略， 多个VAMC使用从本研究中获得的信息来通知实施。我们将 与我们在国家心脏病学和PBM学术细节的合作伙伴合作，传播我们的 这些结果将纳入研究期间定期举行的利益攸关方会议。

Background: VA has experience with strategies to promote guideline-concordant heart failure (HF) care but there is a need for greater innovation. Nudge theory is a field within behavioral science that focuses on the psychology of decision-making and offers a novel solution to improve health care. In this proposed study, we will evaluate two nudge interventions, alerts and peer comparison feedback, that exploit several biases which constitute the theoretical basis supporting behavioral change. Significance: The HF treatment gap is serious, costly, and all-too-common (low adoption of SGLT2i and MRAs). The rates of HF guideline-directed therapy have stagnated in the VA. Our group and others have reported that 34,000 and 21,000 deaths could be averted with optimal implementation of SGLT2i and MRAs, respectively, in the U.S. Innovation & Impact: We will test the effectiveness of a multicomponent nudge strategy (alert + peer comparison) which are rarely conducted compared to single component strategies. Only 10% of clinical-directed nudge interventions in the literature are multicomponent, and none were identified in the VA. This study will create knowledge on how to combine these different strategies which are needed to advance the field further and efficiently allocate VA resources. This study targets an HF treatment gap (SGLT2 and MRA) in which no prior nudge studies have demonstrated efficacy. This proposal utilizes an implementation science (CDS/PRISM) approach to develop nudge strategies which is needed to ensure optimal effectiveness, implementation, and sustainability. Specific Aims: 1) Conduct a formative evaluation to develop two nudge strategies, an informational alert and peer comparison feedback, to encourage clinicians to prescribe MRA and SGLT2 inhibitors. 2) Evaluate preliminary outcomes of the two nudge strategies using the RE-AIM framework. a) Evaluate the preliminary effectiveness of the alert and peer comparison strategies in a four-group design. b) Evaluate the implementation outcomes of the two nudge strategies. i) We will report the following PRISM/RE-AIM outcomes: intervention, recipients, external environment, infrastructure, Reach, Adoption, and Implementation. Methodology: This is a single-center pilot study. For Aim 1, we will conduct key stakeholder interviews and focus groups of clinicians to assess barriers and facilitators to SGLT2 and MRA prescribing and to refine the prototype nudges. For Aim 2, clinicians will be randomized to one of four arms: usual care, informational alert, peer comparison feedback, and combination of alert and peer comparison. We will compare Effectiveness, defined as new prescription of SGLT2 or MRA within 30 days, in the three intervention versus control groups. We will also report other outcomes including safety, Reach, Adoption, and Implementation. Next Steps/Implementation: We will plan to test the nudge strategies in a broader trial of multiple VAMCs using information gained from this study to inform implementation. We will work with our partners in National Cardiology and PBM Academic Detailing to disseminate our findings, and they will be included in periodic stakeholders’ meetings during the study.