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Nguyen OT, Kunta AR, Katoju S, Gheytasvand S, Masoumi N, Tavasolian R, Alishahi Tabriz A, Hong YR, Hanna K, Perkins R, Parekh A, Turner K. Electronic Health Record Nudges and Health Care Quality and Outcomes in Primary Care: A Systematic Review. JAMA Netw Open 2024; 7:e2432760. [PMID: 39287947 PMCID: PMC11409160 DOI: 10.1001/jamanetworkopen.2024.32760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2024] Open
Abstract
Importance Nudges have been increasingly studied as a tool for facilitating behavior change and may represent a novel way to modify the electronic health record (EHR) to encourage evidence-based care. Objective To evaluate the association between EHR nudges and health care outcomes in primary care settings and describe implementation facilitators and barriers. Evidence Review On June 9, 2023, an electronic search was performed in PubMed, Embase, PsycINFO, CINAHL, and Web of Science for all articles about clinician-facing EHR nudges. After reviewing titles, abstracts, and full texts, the present review was restricted to articles that used a randomized clinical trial (RCT) design, focused on primary care settings, and evaluated the association between EHR nudges and health care quality and patient outcome measures. Two reviewers abstracted the following elements: country, targeted clinician types, medical conditions studied, length of evaluation period, study design, sample size, intervention conditions, nudge mechanisms, implementation facilitators and barriers encountered, and major findings. The findings were qualitatively reported by type of health care quality and patient outcome and type of primary care condition targeted. The Risk of Bias 2.0 tool was adapted to evaluate the studies based on RCT design (cluster, parallel, crossover). Studies were scored from 0 to 5 points, with higher scores indicating lower risk of bias. Findings Fifty-four studies met the inclusion criteria. Overall, most studies (79.6%) were assessed to have a moderate risk of bias. Most or all descriptive (eg, documentation patterns) (30 of 38) or patient-centeredness measures (4 of 4) had positive associations with EHR nudges. As for other measures of health care quality and patient outcomes, few had positive associations between EHR nudges and patient safety (4 of 12), effectiveness (19 of 48), efficiency (0 of 4), patient-reported outcomes (0 of 3), patient adherence (1 of 2), or clinical outcome measures (1 of 7). Conclusions and Relevance This systematic review found low- and moderate-quality evidence that suggested that EHR nudges were associated with improved descriptive measures (eg, documentation patterns). Meanwhile, it was unclear whether EHR nudges were associated with improvements in other areas of health care quality, such as effectiveness and patient safety outcomes. Future research is needed using longer evaluation periods, a broader range of primary care conditions, and in deimplementation contexts.
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Affiliation(s)
- Oliver T Nguyen
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Industrial and Systems Engineering, University of Wisconsin at Madison, Madison
| | | | - SriVarsha Katoju
- Department of Community Health and Family Medicine, University of Florida, Gainesville
| | | | - Niloofar Masoumi
- College of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Ronia Tavasolian
- Department of Clinical Science and Nutrition, University of Chester, England
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Oncologic Science, University of South Florida, Tampa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, University of Florida, Gainesville
| | - Karim Hanna
- Department of Family Medicine, University of South Florida, Tampa
| | - Randa Perkins
- Department of Internal Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Arpan Parekh
- College of Medicine, University of Miami, Miami, Florida
| | - Kea Turner
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Oncologic Science, University of South Florida, Tampa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Kien C, Daxenbichler J, Titscher V, Baenziger J, Klingenstein P, Naef R, Klerings I, Clack L, Fila J, Sommer I. Effectiveness of de-implementation of low-value healthcare practices: an overview of systematic reviews. Implement Sci 2024; 19:56. [PMID: 39103927 DOI: 10.1186/s13012-024-01384-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 07/12/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Reducing low-value care (LVC) is crucial to improve the quality of patient care while increasing the efficient use of scarce healthcare resources. Recently, strategies to de-implement LVC have been mapped against the Expert Recommendation for Implementing Change (ERIC) compilation of strategies. However, such strategies' effectiveness across different healthcare practices has not been addressed. This overview of systematic reviews aimed to investigate the effectiveness of de-implementation initiatives and specific ERIC strategy clusters. METHODS We searched MEDLINE (Ovid), Epistemonikos.org and Scopus (Elsevier) from 1 January 2010 to 17 April 2023 and used additional search strategies to identify relevant systematic reviews (SRs). Two reviewers independently screened abstracts and full texts against a priori-defined criteria, assessed the SR quality and extracted pre-specified data. We created harvest plots to display the results. RESULTS Of 46 included SRs, 27 focused on drug treatments, such as antibiotics or opioids, twelve on laboratory tests or diagnostic imaging and seven on other healthcare practices. In categorising de-implementation strategies, SR authors applied different techniques: creating self-developed strategies (n = 12), focussing on specific de-implementation strategies (n = 14) and using published taxonomies (n = 12). Overall, 15 SRs provided evidence for the effectiveness of de-implementation interventions to reduce antibiotic and opioid utilisation. Reduced utilisation, albeit inconsistently significant, was documented in the use of antipsychotics and benzodiazepines, as well as in laboratory tests and diagnostic imaging. Strategies within the adapt and tailor to context, develop stakeholder interrelationships, and change infrastructure and workflow ERIC clusters led to a consistent reduction in LVC practices. CONCLUSION De-implementation initiatives were effective in reducing medication usage, and inconsistent significant reductions were observed for LVC laboratory tests and imaging. Notably, de-implementation clusters such as change infrastructure and workflow and develop stakeholder interrelationships emerged as the most encouraging avenues. Additionally, we provided suggestions to enhance SR quality, emphasising adherence to guidelines for synthesising complex interventions, prioritising appropriateness of care outcomes, documenting the development process of de-implementation initiatives and ensuring consistent reporting of applied de-implementation strategies. REGISTRATION OSF Open Science Framework 5ruzw.
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Affiliation(s)
- Christina Kien
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria.
| | - Julia Daxenbichler
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Viktoria Titscher
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Julia Baenziger
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
| | - Pauline Klingenstein
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Rahel Naef
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
- Centre of Clinical Nursing Science, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Irma Klerings
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Lauren Clack
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | - Julian Fila
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Isolde Sommer
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
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Vázquez-Cancela O, Zapata-Cachafeiro M, Herdeiro MT, Figueiras A, Rodríguez-Fernández A. Dentists' knowledge, attitudes and perceptions of antibiotic prescribing: A systematic review. Prev Med 2024; 185:108043. [PMID: 38901743 DOI: 10.1016/j.ypmed.2024.108043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 06/08/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE This study aims to explore dentists' knowledge, attitudes, and perceptions regarding antibiotic use. METHODS We conducted a systematic review of dentists' knowledge, attitudes and perceptions regarding antibiotic use, by searching the MEDLINE, EMBASE and Web of Science for all original paper published from January 1990 to July 2023, in accordance with the Preferred Reporting Items for systematic Reviews and Meta-analyses (PRISMA 2020) guidelines. RESULTS The review included 37 papers, (7 qualitative and 30 quantitative studies). Modifiable factors (knowledge, attitudes) were reported as being associated with antibiotic prescribing by dentists which were cited in 30 of the 37. These attitudes most frequently identified by dentists were: complacency (22/29); lack of trust (16/29); the need to postpone the dental procedure (17/29); and fear (8/29). Gaps in knowledge were also identified (15/29). Only one of the included articles quantified the influence between the reported modifiable factors and antibiotic prescribing. CONCLUSIONS The review emphasizes that dentists' antibiotic prescribing is predominantly influenced by modifiable factors. This insight informs the potential for targeted interventions to curtail inappropriate antibiotic use, contributing to global efforts in reducing antibiotic resistance. The protocol of this systematic review can be found in PROSPERO under registration no. CRD42021253937.
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Affiliation(s)
- Olalla Vázquez-Cancela
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain; Department of Preventive Medicine, Santiago de Compostela University Teaching Hospital, Santiago de Compostela, Spain
| | - Maruxa Zapata-Cachafeiro
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain; Institute of Health Research of Santiago de Compostela, Santiago de Compostela, Spain.
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, iBiMED-Institute of Biomedicine, University of Aveiro, Aveiro, Portugal
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain; Institute of Health Research of Santiago de Compostela, Santiago de Compostela, Spain
| | - Almudena Rodríguez-Fernández
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain; Institute of Health Research of Santiago de Compostela, Santiago de Compostela, Spain
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Newport K, Langford AV, McEvoy AM, Kelly DV, Smith T, Tannenbaum C, Turner JP. How to change workflow to enhance implementation of professional services in community pharmacies: A deprescribing case study. Can Pharm J (Ott) 2024; 157:164-170. [PMID: 39092083 PMCID: PMC11290586 DOI: 10.1177/17151635241246975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/09/2023] [Indexed: 08/04/2024]
Affiliation(s)
- Kelda Newport
- School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Aili V. Langford
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia
| | - Aisling M. McEvoy
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia
| | - Deborah V. Kelly
- School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Tara Smith
- School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Cara Tannenbaum
- Centre de recherche, Institut universitaire de gériatrie de Montréal, Québec
- Faculté de Médicine, Université de Montréal, Québec
| | - Justin P. Turner
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia
- Centre de recherche, Institut universitaire de gériatrie de Montréal, Québec
- Faculté de Pharmacie, Université de Montréal, Québec
- Faculté de Pharmacie, Laval Université, Québec
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Soames J, Pettigrew LM. Electronic health record-based behaviour change interventions aimed at general practitioners in the UK: a mixed methods systematic review using behaviour change theory. BMJ Open 2024; 14:e080546. [PMID: 38816046 PMCID: PMC11141199 DOI: 10.1136/bmjopen-2023-080546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/24/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES Electronic health record (EHR) systems are used extensively in healthcare; their design can influence clinicians' behaviour. We conducted a systematic review of EHR-based interventions aimed at changing the clinical practice of general practitioners in the UK, assessed their effectiveness and applied behaviour change theory to identify lessons for other settings. DESIGN Mixed methods systematic review. DATA SOURCES MEDLINE, EMBASE, CENTRAL and APA PsycINFO were searched up to March 2023. ELIGIBILITY CRITERIA Quantitative and qualitative findings from randomised controlled trials (RCTs) controlled before-and-after studies and interrupted time series of EHR-based interventions in UK general practice were included. DATA EXTRACTION AND SYNTHESIS Quantitative synthesis was based on Cochrane's Synthesis without Meta-analysis. Interventions were categorised using the Behaviour Change Wheel and MINDSPACE frameworks and effectiveness determined by vote-counting using direction of effect. Inductive thematic synthesis was used for qualitative studies. RESULTS Database searching identified 3824 unique articles; 10 were included (from 2002 to 2021), comprising eight RCTs and two associated qualitative studies. Four of seven quantitative studies showed a positive effect on clinician behaviour and three on patient-level outcomes. Behaviour change techniques that may trigger emotions and required less cognitive engagement appeared to have positive effects. Qualitative findings indicated that interventions reassured clinicians of their decisions but were sometimes ignored. CONCLUSION Despite widespread use, there is little high quality, up-to-date experimental evidence evaluating the effectiveness of EHR-based interventions in UK general practice. The evidence suggested EHR-based interventions may be effective at changing behaviour. Persistent, simple action-oriented prompts appeared more effective than complex interventions requiring greater cognitive engagement. However, studies lacked detail in intervention design and theory behind design choices. Future research should seek to optimise EHR-based behaviour change intervention design and delineate limitations, providing theory-based justification for interventions. This will be of increasing importance with the growing use of EHRs to influence clinicians' decisions. PROSPERO REGISTRATION NUMBER CRD42022341009.
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Affiliation(s)
- Jamie Soames
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Luisa M Pettigrew
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Golden BP, Gilmore-Bykovskyi A. "Nudging" clinicians to communicate more effectively with patients in hospital. BMJ 2023; 383:2678. [PMID: 38101921 DOI: 10.1136/bmj.p2678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Blair P Golden
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Andrea Gilmore-Bykovskyi
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
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McIntyre MT, Saha S, Morris AM, Lapointe-Shaw L, Tang T, Weinerman A, Fralick M, Agarwal A, Verma A, Razak F. Physician antimicrobial prescribing and patient outcomes on general medical wards: a multicentre retrospective cohort study. CMAJ 2023; 195:E1065-E1074. [PMID: 37604522 PMCID: PMC10442238 DOI: 10.1503/cmaj.221732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Variability in antimicrobial prescribing may indicate an opportunity for improvement in antimicrobial use. We sought to measure physician-level antimicrobial prescribing in adult general medical wards, assess the contribution of patient-level factors to antimicrobial prescribing and evaluate the association between antimicrobial prescribing and clinical outcomes. METHODS Using the General Medicine Inpatient Initiative (GEMINI) database, we conducted a retrospective cohort study of physician-level volume and spectrum of antimicrobial prescribing in adult general medical wards in 4 academic teaching hospitals in Toronto, Ontario, between April 2010 and December 2019. We stratified physicians into quartiles by hospital site based on volume of antimicrobial prescribing (days of therapy per 100 patient-days and antimicrobial-free days) and antibacterial spectrum (modified spectrum score). The modified spectrum score assigns a value to each antibacterial agent based on the breadth of coverage. We assessed patient-level differences among physician quartiles using age, sex, Laboratory-based Acute Physiology Score, discharge diagnosis and Charlson Comorbidity Index. We evaluated the association of clinical outcomes (in-hospital 30-day mortality, length of stay, intensive care unit [ICU] transfer and hospital readmission) with antimicrobial volume and spectrum using multilevel modelling. RESULTS The cohort consisted of 124 physicians responsible for 124 158 hospital admissions. The median physician-level volume of antimicrobial prescribing was 56.1 (interquartile range 51.7-67.5) days of therapy per 100 patient-days. We did not find any differences in baseline patient characteristics by physician prescribing quartile. The difference in mean prescribing between quartile 4 and quartile 1 was 15.8 days of therapy per 100 patient-days (95% confidence interval [CI] 9.6-22.0), representing 30% higher antimicrobial prescribing in the fourth quartile than the first quartile. Patient in-hospital deaths, length of stay, ICU transfer and hospital readmission did not differ by physician quartile. In-hospital mortality was higher among patients cared for by prescribers with higher modified spectrum scores (odds ratio 1.13, 95% CI 1.04-1.24). INTERPRETATION We found that physician-level variability in antimicrobial prescribing was not associated with differences in patient characteristics or outcomes in academic general medicine wards. These findings provide support for considering the lowest quartile of physician antimicrobial prescribing within each hospital as a target for antimicrobial stewardship.
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Affiliation(s)
- Mark T McIntyre
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont.
| | - Sudipta Saha
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Andrew M Morris
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Terence Tang
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Adina Weinerman
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Michael Fralick
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Arnav Agarwal
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Amol Verma
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Fahad Razak
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
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Doctor JN, Goldstein NJ, Fox CR, Linder JA, Persell SD, Stewart EP, Knight TK, Meeker D. Clinician Job Satisfaction After Peer Comparison Feedback: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2317379. [PMID: 37289454 PMCID: PMC10251208 DOI: 10.1001/jamanetworkopen.2023.17379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/24/2023] [Indexed: 06/09/2023] Open
Abstract
Importance Interventions that improve clinician performance through feedback should not contribute to job dissatisfaction or staff turnover. Measurement of job satisfaction may help identify interventions that lead to this undesirable consequence. Objective To evaluate whether mean job satisfaction was less than the margin of clinical significance among clinicians who received social norm feedback (peer comparison) compared with clinicians who did not. Design, Setting, and Participants This secondary, preregistered, noninferiority analysis of a cluster randomized trial compared 3 interventions to reduce inappropriate antibiotic prescribing in a 2 × 2 × 2 factorial design from November 1, 2011, to April 1, 2014. A total of 248 clinicians were enrolled from 47 clinics. The sample size for this analysis was determined by the number of nonmissing job satisfaction scores from the original enrolled sample, which was 201 clinicians from 43 clinics. Data analysis was performed from October 12 to April 13, 2022. Interventions Feedback comparing individual clinician performance to top-performing peers, delivered in monthly emails (peer comparison). Main Outcomes and Measures The primary outcome was a response to the following statement: "Overall, I am satisfied with my current job." Responses ranged from 1 (strongly disagree) to 5 (strongly agree). Results A total of 201 clinicians (response rate, 81%) from 43 of the 47 clinics (91%) provided a survey response about job satisfaction. Clinicians were primarily female (n = 129 [64%]) and board certified in internal medicine (n = 126 [63%]), with a mean (SD) age of 48 (10) years. The clinic-clustered difference in mean job satisfaction was greater than -0.32 (β = 0.11; 95% CI, -0.19 to 0.42; P = .46). Therefore, the preregistered null hypothesis that peer comparison is inferior by resulting in at least a 1-point decrease in job satisfaction by 1 in 3 clinicians was rejected. The secondary null hypothesis that job satisfaction was similar among clinicians randomized to social norm feedback was not able to be rejected. The effect size did not change when controlling for other trial interventions (t = 0.08; P = .94), and no interaction effects were observed. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, peer comparison did not lead to lower job satisfaction. Features that may have protected against dissatisfaction include clinicians' agency over the performance measure, privacy of individual performance, and allowing all clinicians to achieve top performance. Trial Registration ClinicalTrials.gov Identifiers: NCT05575115 and NCT01454947.
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Affiliation(s)
- Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Noah J. Goldstein
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California
| | - Craig R. Fox
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California
| | - Jeffrey A. Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen D. Persell
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Emily P. Stewart
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Tara K. Knight
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Daniella Meeker
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Biomedical Informatics & Data Science, Yale University School of Medicine, New Haven, Connecticut
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Raban MZ, Gates PJ, Gamboa S, Gonzalez G, Westbrook JI. Effectiveness of non-interruptive nudge interventions in electronic health records to improve the delivery of care in hospitals: a systematic review. J Am Med Inform Assoc 2023:7163187. [PMID: 37187160 DOI: 10.1093/jamia/ocad083] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/31/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES To describe the application of nudges within electronic health records (EHRs) and their effects on inpatient care delivery, and identify design features that support effective decision-making without the use of interruptive alerts. MATERIALS AND METHODS We searched Medline, Embase, and PsychInfo (in January 2022) for randomized controlled trials, interrupted time-series and before-after studies reporting effects of nudge interventions embedded in hospital EHRs to improve care. Nudge interventions were identified at full-text review, using a pre-existing classification. Interventions using interruptive alerts were excluded. Risk of bias was assessed using the ROBINS-I tool (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies or the Cochrane Effective Practice and Organization of Care Group methodology for randomized trials. Study results were summarized narratively. RESULTS We included 18 studies evaluating 24 EHR nudges. An improvement in care delivery was reported for 79.2% (n = 19; 95% CI, 59.5-90.8) of nudges. Nudges applied were from 5 of 9 possible nudge categories: change choice defaults (n = 9), make information visible (n = 6), change range or composition of options (n = 5), provide reminders (n = 2), and change option-related effort (n = 2). Only one study had a low risk of bias. Nudges targeted ordering of medications, laboratory tests, imaging, and appropriateness of care. Few studies evaluated long-term effects. DISCUSSION Nudges in EHRs can improve care delivery. Future work could explore a wider range of nudges and evaluate long-term effects. CONCLUSION Nudges can be implemented in EHRs to improve care delivery within current system capabilities; however, as with all digital interventions, careful consideration of the sociotechnical system is crucial to enhance their effectiveness.
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Affiliation(s)
- Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Peter J Gates
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Sarah Gamboa
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Gabriela Gonzalez
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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