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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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Cloyd CP, Macedone D, Merandi J, Pierson S, Sellas Wcislo M, Lutmer J, MacDonald J, Ayad O, Kalata L, Thompson RZ. A Quality Initiative to Improve Appropriate Medication Dosing in Pediatric Patients with Obesity. Pediatr Qual Saf 2024; 9:e741. [PMID: 38868757 PMCID: PMC11167219 DOI: 10.1097/pq9.0000000000000741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/17/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year. Methods The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department. Results Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months. Conclusions Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.
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Affiliation(s)
- Colleen P. Cloyd
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Danielle Macedone
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Nationwide Children’s Hospital Center for Clinical Excellence, Columbus, Ohio
| | - Jenna Merandi
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Shawn Pierson
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Maria Sellas Wcislo
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Jeffrey Lutmer
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Jennifer MacDonald
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Onsy Ayad
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Lindsay Kalata
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - R. Zachary Thompson
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
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3
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Nuckols TK, Chen PG, Shetty KD, Brara HS, Anand N, Qureshi N, Skaggs DL, Doctor JN, Pevnick JM, Mannion AF. Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons. PLoS One 2024; 19:e0300475. [PMID: 38640131 PMCID: PMC11029649 DOI: 10.1371/journal.pone.0300475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/20/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. METHODS The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). RESULTS Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). CONCLUSIONS Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.
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Affiliation(s)
- Teryl K. Nuckols
- RAND Corporation, Santa Monica, CA, United States of America
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Peggy G. Chen
- RAND Corporation, Santa Monica, CA, United States of America
| | | | - Harsimran S. Brara
- Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States of America
| | - Neel Anand
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Nabeel Qureshi
- RAND Corporation, Santa Monica, CA, United States of America
| | - David L. Skaggs
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, Los Angeles, CA, United States of America
| | - Joshua M. Pevnick
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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4
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Warkentin L, Hueber S, Kühlein T, Scherer M. Insights on the German College of General Practitioners and Family Physicians (DEGAM) guideline addressing medical overuse. BMJ Evid Based Med 2024:bmjebm-2023-112697. [PMID: 38395593 DOI: 10.1136/bmjebm-2023-112697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Lisette Warkentin
- Institute of General Practice, Uniklinikum Erlangen, Erlangen, Germany
| | - Susann Hueber
- Institute of General Practice, Uniklinikum Erlangen, Erlangen, Germany
| | - Thomas Kühlein
- Institute of General Practice, Uniklinikum Erlangen, Erlangen, Germany
| | - Martin Scherer
- Institute and Polyclinic for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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5
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Krishnamoorthy V, Harris R, Chowdhury AM, Bedoya A, Bartz R, Raghunathan K. Building Learning Healthcare Systems for Critical Care Medicine. Anesthesiology 2024; 140:817-823. [PMID: 38345893 DOI: 10.1097/aln.0000000000004847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
Learning healthcare systems are an evolving way of integrating informatics, analytics, and continuous improvement into daily practice in healthcare. This article discusses strategies to build learning healthcare systems for critical care medicine.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Division of Critical Care Medicine; Critical Care and Perioperative Population Health Research Program, Department of Anesthesiology; and Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Ronald Harris
- Duke University School of Medicine, Durham, North Carolina
| | - Ananda M Chowdhury
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Armando Bedoya
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Raquel Bartz
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Karthik Raghunathan
- Department of Anesthesiology, Division of Critical Care Medicine; Critical Care and Perioperative Population Health Research Program, Department of Anesthesiology; and Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Lee AEJ, Ithinin S, Tan NC. Physician factors affecting patient preferences in selecting a primary care provider: A qualitative research study in Singapore. PLoS One 2024; 19:e0298823. [PMID: 38427651 PMCID: PMC10906824 DOI: 10.1371/journal.pone.0298823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/30/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Care continuity by a dedicated, well-trained primary care physician (PCP) has shown to improve health outcomes of patients with non-communicable diseases (NCDs). In Singapore's fee-for-service primary care system, patients can choose to consult any PCP in either a public (polyclinic), private (General Practitioners/ GP), or both types of clinics, resulting in potential fragmented care. Decision-making by patients in selecting their preferred PCP remains unclear. This study aims to explore the personal factors influencing the choice of PCP among patients with NCDs in primary care. METHODS This qualitative research study was conducted in a typical polyclinic. In-depth interviews were conducted on patients with NCDs. Purposive sampling was implemented to enrol patients who had previously consulted PCPs in polyclinics and GP clinics, garnering their perspectives and experiences of care received from both providers. Interviews were audio-recorded, transcribed, and audited. Data was coded and analysed using thematic content analysis to identify emerging themes. The physician-specific factors which influence patients' decision-making of PCP selection are presented here. RESULTS Twenty-one Asian patients aged 38 to 82 years were interviewed. They preferred PCPs with an approachable and genuine demeanour, exhibiting empathy and compassion. They valued the PCPs' verbal, non-verbal and listening skills. Regarding professional qualities, patients wanted PCPs to demonstrate competency and a patient-centred care approach. Some selected their PCP based on compatible age and gender that they felt comfortable with. Establishing good rapport with their PCP and maintaining continuity of care were deemed as major factors in patients' PCP selection. CONCLUSION Patients tended to select PCPs based on their personal characteristics, interpersonal skills, professional attributes, demographics, and the physician-patient relationship. PCPs should be aware of these attributes and demonstrate them during their patient interaction. Leveraging on this enables PCPs to build rapport with their patients and maintain care continuity to optimize their health outcomes.
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Affiliation(s)
| | | | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore, Singapore
- SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
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Jankulov A, As-Sanie S, Zimmerman C, Virzi J, Srinivasan S, Choe HM, Brummett CM. Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study. J Pain Res 2024; 17:667-675. [PMID: 38375407 PMCID: PMC10875180 DOI: 10.2147/jpr.s432262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/28/2023] [Indexed: 02/21/2024] Open
Abstract
Purpose The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy. Patients and Methods The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert. Results 332 patients were included. The BPA triggered 29 times. The following actions were taken among 16 patients for whom the BPA triggered: "override the alert" (n=13); "cancel the alert" (n=2); and 'remove the opioid order set' (n=1). 12/16 patients had discharge prescriptions: one patient received 20 tablets; two received 10 tablets; and nine received 15 tablets. Top reasons for over prescribing included concerns for pain control and lack of alternatives. Conclusion Implementing a post-discharge opioid prescribing BPA aligned opioid prescribing following benign minimally invasive hysterectomy with guideline recommendations.
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Affiliation(s)
- Alexandra Jankulov
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
| | - Sawsan As-Sanie
- Department of Obstetrics & Gynecology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Christopher Zimmerman
- Department of Health Information and Technology Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jessica Virzi
- Department of Precision Health, University of Michigan Health System, Ann Arbor, MI, USA
| | - Sudharsan Srinivasan
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Hae Mi Choe
- Department of Health Information and Technology Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI, USA
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8
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Schell JO, Schenker Y, Piscitello G, Belin SC, Chiu EJ, Zapf RL, Kip PL, Marroquin OC, Donahoe MP, Holder-Murray J, Arnold RM. Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation. J Pain Symptom Manage 2023; 66:603-610.e3. [PMID: 37532159 PMCID: PMC10828667 DOI: 10.1016/j.jpainsymman.2023.07.015] [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: 05/08/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023]
Abstract
CONTEXT Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings. OBJECTIVES We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients. METHODS Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania. Intervention included integration of a 90-day mortality prediction model grouping patients into low, intermediate, and high risk; a centralized goals of care note; and automated notifications and targeted palliative consults. We compared documented goals of care discussions by risk score before and after implementation. RESULTS Of the 12,571 patients hospitalized preimplementation and 10,761 postimplementation, 1% were designated high risk and 11% intermediate risk of mortality. Postimplementation, goals of care documentation increased for high (17.6%-70.8%, P< 0.0001) and intermediate risk patients (9.6%-28.0%, P < 0.0001). For intermediate risk patients, the percentage of goals of care documentation performed by palliative medicine specialists increased from pre- to postimplementation (52.3%-71.2%, P = 0.0002). For high-risk patients, the percentage of goals of care documentation completed by the primary service increased from pre-to postimplementation (36.8%-47.1%, P = 0.5898, with documentation performed by palliative medicine specialists slightly decreasing from pre- to postimplementation (63.2%-52.9%, P = 0.5898). CONCLUSIONS Implementation of a goals of care initiative using a mortality prediction model significantly increased goals of care documentation especially among high-risk patients. Further study to assess strategies to increase goals of care documentation for intermediate risk patients is needed especially by nonspecialty palliative care.
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Affiliation(s)
- Jane O Schell
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Renal-Electrolyte Division (J.O.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gina Piscitello
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shane C Belin
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric J Chiu
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel L Zapf
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | - Paula L Kip
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | | | - Michael P Donahoe
- Division of Pulmonary, Allergy, and Critical Care Medicine (M.P.D.), Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Holder-Murray
- Departments of Surgery and Anesthesiology and Perioperative Medicine (J.H.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
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Joo JH, Liao JM. Using peer comparisons to address low-value care: Lessons for a persistent challenge. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100721. [PMID: 37972418 DOI: 10.1016/j.hjdsi.2023.100721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Joseph H Joo
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, WA, USA
| | - Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, WA, USA.
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Paz-Martin D, Arnal-Velasco D. Can we nudge to reduce the perioperative low value care? Decision making factors influencing safe practice implementation. Curr Opin Anaesthesiol 2023; 36:698-705. [PMID: 37767927 DOI: 10.1097/aco.0000000000001315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
PURPOSE OF THE REVIEW Highlight sources of low-value care (LVC) during the perioperative period help understanding the decision making behind its persistence, the barriers for change, and the potential implementation strategies to reduce it. RECENT FINDINGS The behavioural economics science spread of use through aligned strategies or nudge units offer an opportunity to improve success in the LVC reduction. SUMMARY LVC, such as unneeded surgeries, or preanaesthesia tests for low-risk surgeries in low-risk patients, is a relevant source of waste and preventable harm, most especially in the perioperative period. Despite the international focus on it, initial efforts to reduce it in the last decade have not clearly shown a sustainable improvement. Understanding the shared decision-making process and the barriers to be expected when tackling LVC is the first step to build the change. Applying a structured strategy based on the behavioural science principles may be the path to increasing high value care in an effective an efficient way. It is time to foster nudge units at different healthcare system levels.
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Affiliation(s)
| | - Daniel Arnal-Velasco
- Unit of Anesthesiology and Reanimation, Hospital Universitario Fundacion Alcorcon, Alcorcon, Spain
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Wang SY, Larrain N, Groene O. Can peer effects explain prescribing appropriateness? a social network analysis. BMC Med Res Methodol 2023; 23:252. [PMID: 37898770 PMCID: PMC10613382 DOI: 10.1186/s12874-023-02048-7] [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: 05/17/2022] [Accepted: 09/25/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Optimizing prescribing practices is important due to the substantial clinical and financial costs of polypharmacy and an increasingly aging population. Prior research shows the importance of social relationships in driving prescribing behaviour. Using social network analysis, we examine the relationship between a physician practices' connectedness to peers and their prescribing performance in two German regions. METHODS We first mapped physician practice networks using links established between two practices that share 8 or more patients; we calculated network-level (density, average path length) and node-level measures (degree, betweenness, eigenvector). We defined prescribing performance as the total number of inappropriate medications prescribed or appropriate medications not prescribed (PIMs) to senior patients (over the age of 65) during the calendar year 2016. We used FORTA (Fit fOR The Aged) algorithm to classify medication appropriateness. Negative binomial regression models estimate the association between node-level measures and prescribing performance of physician practices controlling for patient comorbidity, provider specialization, percentage of seniors in practice, and region. We conducted two sensitivity analyses to test the robustness of our findings - i) limiting the network mapping to patients younger than 65; ii) limiting the network ties to practices that share more than 25 patients. RESULTS We mapped two patient-sharing networks including 436 and 270 physician practices involving 28,508 and 20,935 patients and consisting of 217,126 and 154,274 claims in the two regions respectively. Regression analyses showed a practice's network connectedness as represented by degree, betweenness, and eigenvector centrality, is significantly negatively associated with prescribing performance (degree-bottom vs. top quartile aRR = 0.04, 95%CI: 0.035,0.045; betweenness-bottom vs. top quartile aRR = 0.063 95%CI: 0.052,0.077; eigenvector-bottom vs. top quartile aRR = 0.039, 95%CI: 0.034,0.044). CONCLUSIONS Our study provides evidence that physician practice prescribing performance is associated with their peer connections and position within their network. We conclude that practices occupying strategic positions at the edge of networks with advantageous access to novel information are associated with better prescribing outcomes, whereas highly connected practices embedded in insulated information environments are associated with poor prescribing performance.
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Affiliation(s)
- Sophie Y Wang
- Hamburg Center for Health Economics, Esplanade 36, 20354, Hamburg, Germany.
- OptiMedis AG, Buchardstraße 17, 20095, Hamburg, Germany.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Nicolas Larrain
- Hamburg Center for Health Economics, Esplanade 36, 20354, Hamburg, Germany
- Employment, Labour and Social Affairs, Health Division, OECD, 2 Rue André Pascal, Cedex 16, 75775, Paris, France
| | - Oliver Groene
- OptiMedis AG, Buchardstraße 17, 20095, Hamburg, Germany
- Faculty of Management, Economics and Society, University of Witten, Alfred-Herrhausen-Straße 50, 58455, HerdeckeWitten, Germany
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12
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Schoenborn NL, Pollack CE, Boyd CM. When should electronic medical records reminders for cancer screening stop?-Results from a national physician survey. J Am Geriatr Soc 2023; 71:2878-2885. [PMID: 37224393 DOI: 10.1111/jgs.18412] [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: 01/06/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Many older adults are screened for breast and colorectal cancers beyond guideline recommended thresholds. Electronic medical record (EMR) reminders are commonly used to prompt cancer screening. Behavioral economics theory suggests that changing the default settings for these reminders can be effective to reduce over-screening. We examined physician perspectives about acceptable thresholds for stopping EMR cancer screening reminders. METHODS In a national survey of 1200 primary care physicians (PCP) and 600 gynecologists randomly selected from the AMA Masterfile, we asked physicians to choose whether EMR reminders for cancer screening should stop based on a list of criteria that included age, life expectancy, specific serious illnesses, and functional limitations. Physicians could choose multiple responses. PCPs were randomized to questions about breast or colorectal cancer screening. RESULTS A total of 592 physicians participated (adjusted response rate 54.1%). 54.6% chose age and 71.8% chose life expectancy as criteria for stopping EMR reminders; only 30.6% chose functional limitations. Regarding age thresholds, 52.4% chose ages ≤75, 42.0% chose a threshold between 75 and 85, 5.6% would not stop reminders even at age 85. Regarding life expectancy thresholds, 32.0% chose ≥10 years, 53.1% chose a threshold between 5 and 9 years, 14.9% would not stop reminders even when life expectancy is <5 years. CONCLUSIONS We found that many physicians would continue EMR reminders for cancer screening even in light of older age, limited life expectancy, and functional limitations. This may reflect reluctance to stop cancer screening and/or reluctance to stop EMR reminders so that physicians can retain control to decide for individual patients, for example, to assess patient preference and ability to tolerate treatment. There was consensus for stopping EMR reminders at ages 85+ and <5-year life expectancy. Interventions that seek to reduce over-screening by suppressing EMR reminders may be important for these groups but may have limited physician buy-in outside these thresholds.
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Affiliation(s)
- Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Craig E Pollack
- School of Public Health, Department of Health Policy and Management, Johns Hopkins University Bloomberg, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Govathson C, Long LC, Russell CA, Moolla A, Pascoe S, Nichols BE. A modelling framework for translating discrete choice experiment results into cost-effectiveness estimates: an application to designing tailored and scalable HIV and contraceptive services for adolescents in Gauteng, South Africa. J Int AIDS Soc 2023; 26:e26124. [PMID: 37463870 PMCID: PMC10354002 DOI: 10.1002/jia2.26124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 05/17/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION South African youth and adolescents face a high burden of (Sexually Transmitted Infections) STIs, HIV and unintended pregnancies, but uptake of services remains low. To address this, tailored and scalable interventions are urgently needed. We developed a framework to fill the gap and translate the impact of facility-level attributes into a cost-effectiveness analysis for increasing HIV/contraceptive service uptake in adolescents using a discrete choice experiment (DCE). METHODS We used a DCE (n = 805) conducted in Gauteng, South Africa, which found that staff attitude, confidentiality, Wi-Fi, subsidized food, afternoon hours and youth-only services were preferred attributes of health services. Based on this, we simulated the uptake of services adapted for these preferences. We divided preferences into modifiable attributes that could readily be adapted (e.g. Wi-Fi), and challenging to modify (more nuanced attributes that are more challenging to cost and evaluate): staff attitude and estimated the incremental change in the uptake of services using adapted services. Costs for modifiable preferences were estimated using data from two clinics in South Africa (2019 US$). We determined the incremental cost-effectiveness ratio (ICER) for additional adolescents using services of 15 intervention combinations, and report the results of interventions on the cost-effectiveness frontier. RESULTS Greatest projected impact on uptake was from friendly and confidential services, both of which were considered challenging to modify (18.5% 95% CI: 13.0%-24.0%; 8.4% 95% CI: 3.0%-14.0%, respectively). Modifiable factors on their own resulted in only small increases in expected uptake. (Food: 2.3% 95% CI: 4.0%-9.00%; Wi-Fi: 3.0% 95% CI: -4.0% to 10.0%; Youth-only services: 0.3% 95% CI: -6.0% to 7.0%; Afternoon services: 0.8% 95% CI: -6.0% to 7.0%). The order of interventions on the cost-effectiveness frontier are Wi-Fi and youth-only services (ICER US$7.01-US$9.78 per additional adolescent utilizing HIV and contraceptive services), Wi-Fi, youth-only services and food (ICER US$9.32-US$10.45), followed by Wi-Fi, youth-only services and extended afternoon hours (ICER US$14.46-US$43.63). CONCLUSIONS Combining DCE results and costing analyses within a modelling framework provides an innovative way to inform decisions on effective resource utilization. Modifiable preferences, such as Wi-Fi provision, youth-only services and subsidized food, have the potential to cost-effectively increase the proportion of adolescents accessing HIV and contraceptive services.
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Affiliation(s)
- Caroline Govathson
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lawrence C Long
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, 02118, USA
| | - Colin A Russell
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, 02118, USA
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Aneesa Moolla
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brooke E Nichols
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, 02118, USA
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Leger P, Caldas V, Festa C, Hutchinson T, Jordan S. Translating theory into clinical practice: a qualitative study of clinician perspectives implementing whole person care. BMJ Open Qual 2023; 12:e002164. [PMID: 37400159 DOI: 10.1136/bmjoq-2022-002164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 06/11/2023] [Indexed: 07/05/2023] Open
Abstract
Whole Person Care (WPC) is an emerging framework that emphasises the clinician's role in empowering patient healing. However, reliably translating a framework's theory into practice is a recognised challenge for clinicians. Observational studies have revealed discrepancies between a clinician's stated values in theory and how these may be implemented in practice. The aim of this qualitative study is to bridge the gap between the theory of WPC and its practical implementation by clinicians. We interviewed a diverse group of 34 clinicians attending the 2017 International Whole Person Care Congress to explore (1) their conceptions of WPC in theory as well as (2) how they monitor their practice in real time. Data were analysed using Grounded Theory Methodology. Preliminary results were presented in the form of a workshop at the 2019 International Whole Person Care Congress to validate our findings with relevant stakeholders. The results revealed a vision of WPC that highlighted themes of the clinician's way of being, seeing the person beyond the disease, and the clinician-patient relationship. Our results demonstrate that clinicians use a range of strategies to monitor their practice in real time. Mindfulness and self-awareness were frequently cited as being crucial to this ability of self-regulating their practice. This study helps establish a unifying framework of WPC based on a diverse range of clinician-reported experiences. More importantly, it sheds light on the range of strategies employed by clinicians who monitor their practice in real time. These collected insights will be of interest to any clinician interested in translating their stated values into their clinical practice more reliably.
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Affiliation(s)
- Philip Leger
- Programs in Whole Person Care, McGill University, Montréal, Québec, Canada
| | - Valerie Caldas
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Carolina Festa
- Division of General Internal Medicine, McGill University, Montréal, Québec, Canada
| | - Tom Hutchinson
- Programs in Whole Person Care, McGill University, Montréal, Québec, Canada
| | - Steven Jordan
- Department of Integrated Studies in Education, McGill University, Montréal, Québec, Canada
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Choi S, O’Grady MA, Cleland CM, Knopf E, Hong S, D’Aunno T, Bao Y, Ramsey KS, Neighbors CJ. Clinics Optimizing MEthadone Take-homes for opioid use disorder (COMET): Protocol for a stepped-wedge randomized trial to facilitate clinic level changes. PLoS One 2023; 18:e0286859. [PMID: 37294821 PMCID: PMC10256218 DOI: 10.1371/journal.pone.0286859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 06/11/2023] Open
Abstract
INTRODUCTION Regulatory changes made during the COVID-19 public health emergency (PHE) that relaxed criteria for take-home dosing (THD) of methadone offer an opportunity to improve quality of care with a lifesaving treatment. There is a pressing need for research to study the long-term effects of the new PHE THD rules and to test data-driven interventions to promote more effective adoption by opioid treatment programs (OTPs). We propose a two-phase project to develop and test a multidimensional intervention for OTPs that leverages information from large State administrative data. METHODS AND ANALYSIS We propose a two-phased project to develop then test a multidimensional OTP intervention to address clinical decision making, regulatory confusion, legal liability concerns, capacity for clinical practice change, and financial barriers to THD. The intervention will include OTP THD specific dashboards drawn from multiple State databases. The approach will be informed by the Health Equity Implementation Framework (HEIF). In phase 1, we will employ an explanatory sequential mixed methods design to combine analysis of large state administrative databases-Medicaid, treatment registry, THD reporting-with qualitative interviews to develop and refine the intervention. In phase 2, we will conduct a stepped-wedge trial over three years with 36 OTPs randomized to 6 cohorts of a six-month clinic-level intervention. The trial will test intervention effects on OTP-level implementation outcomes and patient outcomes (1) THD use; 2) retention in care; and 3) adverse healthcare events). We will specifically examine intervention effects for Black and Latinx clients. A concurrent triangulation mixed methods design will be used: quantitative and qualitative data collection will occur concurrently and results will be integrated after analysis of each. We will employ generalized linear mixed models (GLMMs) in the analysis of stepped-wedge trials. The primary outcome will be weekly or greater THD. The semi-structured interviews will be transcribed and analyzed with Dedoose to identify key facilitators, barriers, and experiences according to HEIF constructs using directed content analysis. DISCUSSION This multi-phase, embedded mixed methods project addresses a critical need to support long-term practice changes in methadone treatment for opioid use disorder following systemic changes emerging from the PHE-particularly for Black and Latinx individuals with opioid use disorder. By combining findings from analyses of large administrative data with lessons gleaned from qualitative interviews of OTPs that were flexible with THD and those that were not, we will build and test the intervention to coach clinics to increase flexibility with THD. The findings will inform policy at the local and national level.
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Affiliation(s)
- Sugy Choi
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Megan A. O’Grady
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Charles M. Cleland
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Elizabeth Knopf
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Sueun Hong
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
- New York University Wagner School of Public Policy, New York, NY, United States of America
| | - Thomas D’Aunno
- New York University Wagner School of Public Policy, New York, NY, United States of America
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States of America
| | - Kelly S. Ramsey
- New York State Office of Addiction Services and Supports (OASAS), New York, NY, United States of America
| | - Charles J. Neighbors
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
- New York University Wagner School of Public Policy, New York, NY, United States of America
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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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17
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Woods-Hill CZ, Nelson MN, Eriksen W, Rendle KA, Beidas RS, Bonafide CP, Brajcich MR, Milstone AM, Shea JA. Determinants of Blood Culture Use in Critically Ill Children: A Multicenter Qualitative Study. Pediatr Qual Saf 2023; 8:e647. [PMID: 37051407 PMCID: PMC10085482 DOI: 10.1097/pq9.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/11/2023] [Indexed: 04/14/2023] Open
Abstract
Blood cultures are fundamental in diagnosing and treating sepsis in the pediatric intensive care unit (PICU), but practices vary widely. Overuse can lead to false positive results and unnecessary antibiotics. Specific factors underlying decisions about blood culture use and overuse are unknown. Therefore, we aimed to identify perceived determinants of blood culture use in the PICU. Methods We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics. Results We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts. Conclusions Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia Pa
| | - Maria N. Nelson
- University of Pennsylvania Mixed Methods Research Laboratory
| | | | | | | | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle R. Brajcich
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Judy A. Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Ahomäki I, Böckerman P, Pehkonen J, Saastamoinen L. Effect of Information Intervention on Prescribing Practice for Neuropathic Pain in Older Patients: A Nationwide Register-Based Study. Drugs Aging 2023; 40:81-88. [PMID: 36633822 PMCID: PMC9883359 DOI: 10.1007/s40266-022-00993-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Management of prescription medicines is challenging for older patients due to frail health and the prevalence of multiple chronic conditions. A salient policy challenge of prescribing practices is that all physicians are not well informed about the national clinical guidelines. A feasible policy intervention to mitigate the harms caused by Potentially Inappropriate Medications is to influence the frequency of prescribing and other prescribing attributes of the drugs by providing accurate and up-to-date information about the national clinical guidelines. OBJECTIVES The objective of this study was to examine the effect of a nationwide information intervention on physicians' prescribing practices and patients' healthcare utilization. METHODS We used a quasi-experimental research design based on difference-in-differences variation and nationwide register data on prescribers and purchasers of pregabalin, nortriptyline, and amitriptyline combinations in Finland between January 2018 and May 2019. The study included 68,914 patients and 11,432 physicians. RESULTS We found that the information letter sent to all prescribers of pregabalin, nortriptyline, or amitriptyline combinations to patients aged 75 years or older decreased the probability of prescribing of these medications. The estimated effect of - 3.3 percentage points (95% confidence interval [- 0.041, - 0.024]) corresponds to a 29% reduction compared to the baseline mean of the outcome. The filled quantity, measured in Defined Daily Doses, of pregabalin, nortriptyline, and amitriptyline combinations per month was reduced by 11.7% [- 14.5% to - 8.9%] among patients aged 75 years or older. No effect on patients' healthcare utilization was observed. CONCLUSIONS Findings of the study suggest that personal information intervention was an effective policy tool for nudging physicians to reduce prescribing of potentially inappropriate medicines, whereas the reduction in prescribing was not accompanied by improvements or adverse effects in patients' health.
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Affiliation(s)
- Iiro Ahomäki
- School of Business and Economics, University of Jyväskylä, PO Box 35, 40014, Jyvaskyla, Finland. .,The Social Insurance Institution of Finland, Helsinki, Finland.
| | - Petri Böckerman
- grid.9681.60000 0001 1013 7965School of Business and Economics, University of Jyväskylä, PO Box 35, 40014 Jyvaskyla, Finland
| | - Jaakko Pehkonen
- grid.9681.60000 0001 1013 7965School of Business and Economics, University of Jyväskylä, PO Box 35, 40014 Jyvaskyla, Finland
| | - Leena Saastamoinen
- grid.460437.20000 0001 2186 1430The Social Insurance Institution of Finland, Helsinki, Finland
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Affiliation(s)
- Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois
| | - Stephen D Persell
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Reblin M, Ketcher D, Vadaparampil ST. Care for the Cancer Caregiver: a Qualitative Study of Facilitators and Barriers to Caregiver Integration and Support. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1634-1640. [PMID: 33783762 PMCID: PMC8491125 DOI: 10.1007/s13187-021-02001-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 06/12/2023]
Abstract
Informal family caregivers are critically important for patient care throughout the cancer care trajectory. Family-centered care, which seeks to integrate family members as experts, is a framework that values partnerships with family members and can benefit both the physical and psychosocial health of patients. However, little standardization or system-level implementation of family-centered care models to integrate and support family caregivers have emerged in adult oncology care settings in the USA. To better understand potential barriers and facilitators to the integration and support of family caregivers in cancer care settings, we conducted semi-structured interviews with informal family caregivers (n = 12) and members of the cancer center leadership team and health care providers (n = 11) at an NCI-designated Comprehensive Cancer Center. We frame our results using the social ecological model and identified facilitators and barriers at the individual, interpersonal, and system level. While caregivers and team members were able to identify facilitators and barriers at the individual (i.e., caregivers are motivated to learn, but overwhelmed and focused only on the patient) and interpersonal levels (i.e., relationships are a valuable resource, but communication is sometimes challenging), team members were more likely to identify system-level barriers (i.e., constraints within the larger healthcare structure). To implement family-centered care in cancer settings, it is incumbent on the healthcare system to pursue standardization of communication, programs that facilitate family integration and support, and advocate for policy change. Barriers must be addressed at multiple levels to provide inclusive and supportive environments for all patients and their families.
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Affiliation(s)
- Maija Reblin
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA.
| | - Dana Ketcher
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA
| | - Susan T Vadaparampil
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA
- Office of Community Outreach, Engagement and Equity, Moffitt Cancer Center, 12902 USF Magnolia Dr, Tampa, FL, USA
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Wolf A, Sant'Anna A, Vilhelmsson A. Using nudges to promote clinical decision making of healthcare professionals: A scoping review. Prev Med 2022; 164:107320. [PMID: 36283484 DOI: 10.1016/j.ypmed.2022.107320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/25/2022] [Accepted: 10/18/2022] [Indexed: 10/31/2022]
Abstract
Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.
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Affiliation(s)
- Axel Wolf
- University of Gothenburg, Centre for Person-Centred Care (GPCC), Sweden; University of Gothenburg, Institute of Health and Care Sciences, Sahlgrenska Academy, Sweden
| | | | - Andreas Vilhelmsson
- Lund University, Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Sweden.
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Hallek M, Ockenfels A, Wiesen D. Behavioral Economics Interventions to Improve Medical Decision-Making. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:633-639. [PMID: 35912421 PMCID: PMC9764346 DOI: 10.3238/arztebl.m2022.0275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 09/30/2021] [Accepted: 04/07/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND In medicine, a wide gap exists between the medical care that ought to be possible in the light of the current state of medical research and the care that is actually provided. Behavioral biases and noise are two major reasons for this. METHODS We present the findings of a selective literature review and illustrate how interventions based on behavioral economics can help physicians make better decisions and thereby improve treatment outcomes. RESULTS A number of behavioral economics interventions, making use of, for example, default settings, active decision rules, social norms, and self-commitments, may improve physicians' clinical decision-making. Evidence on long-term effects is, however, mostly lacking. CONCLUSION Despite their apparent potential, the application of behavioral economic interventions to improve medical decisionmaking is still in its infancy, particularly in Germany.
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Affiliation(s)
- Michael Hallek
- University Hospital of Cologne, Internal Medicine Clinic I and Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO)
| | - Axel Ockenfels
- Cologne University, Department of Economics, Center for Social and Economic Behavior (C-SEB) and Cluster of Excellence ECONtribute
| | - Daniel Wiesen
- Cologne University, Seminar for General Business Administration and Management in Healthcare and Center for Social and Economic Behavior (C-SEB),*Seminar for General Business Administration and Management in Healthcare University of Cologne Albertus-Magnus-Platz 50931 Cologne
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Kraemer KL, Althouse AD, Salay M, Gordon AJ, Wright E, Anisman D, Cochran G, Fischer G, Gellad WF, Hamm M, Kern M, Wasan AD. Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain: A Cluster Randomized Clinical Trial. JAMA HEALTH FORUM 2022; 3:e222263. [PMID: 35983579 PMCID: PMC9338412 DOI: 10.1001/jamahealthforum.2022.2263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/01/2022] [Indexed: 12/31/2022] Open
Abstract
Importance Prescription opioids can treat acute pain in primary care but have potential for unsafe use and progression to prolonged opioid prescribing. Objective To compare clinician-facing interventions to prevent unsafe opioid prescribing in opioid-naive primary care patients with acute noncancer pain. Design Setting and Participants We conducted a multisite, cluster-randomized, 2 × 2 factorial, clinical trial in 3 health care systems that comprised 48 primary care practices and 525 participating clinicians from September 2018 through January 2021. Patient participants were opioid-naive outpatients, 18 years or older, who presented for a qualifying clinic visit with acute noncancer musculoskeletal pain or nonmigraine headache. Interventions Practices randomized to: (1) control; (2) opioid justification; (3) monthly clinician comparison emails; or (4) opioid justification and clinician comparison. All groups received opioid prescribing guidelines via the electronic health record at the time of a new opioid prescription. Main Outcomes and Measures Primary outcome measures were receipt of an initial opioid prescription at the qualifying clinic visit. Other outcomes were opioid prescribing for more than 3 months and a concurrent opioid/benzodiazepine prescription over 12-month follow-up. Results Among 22 616 enrolled patient participants (9740 women [43.1%]; 64 American Indian/Alaska Native [0.3%]; 590 Asian [2.6%], 1120 Black/African American [5.0%], 1777 Hispanic [7.9%], 225 Native Hawaiian/Pacific Islander [1.0%], and 18 981 White [83.9%] individuals), the initial opioid prescribing rates at the qualifying clinic visit were 3.1% in the total sample, 4.2% in control, 3.6% in opioid justification, 2.6% in clinician comparison, and 1.9% in opioid justification and clinician comparison. Compared with control, the adjusted odds ratio (aOR) for a new opioid prescription was 0.74 (95% CI, 0.46-1.18; P = .20) for opioid justification and 0.60 (95% CI, 0.38-0.96; P = .03) for clinician comparison. Compared with control, clinician comparison was associated with decreased odds of opioid therapy of more than 3 months (aOR, 0.79; 95% CI, 0.69-0.91; P = .001) and concurrent opioid/benzodiazepine prescription (aOR, 0.85; 95% CI, 0.72-1.00; P = .04), whereas opioid justification did not have a significant effect. Conclusions and Relevance In this cluster randomized clinical trial, comparison emails decreased the proportion of opioid-naive patients with acute noncancer pain who received an opioid prescription, progressed to treatment with long-term opioid therapy, or were exposed to concurrent opioid and benzodiazepine therapy. Health care systems can consider adding clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing. Trial Registration ClinicalTrials.gov Identifier: NCT03537573.
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Affiliation(s)
- Kevin L Kraemer
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrew D Althouse
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Melessa Salay
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam J Gordon
- University of Utah School of Medicine, Salt Lake City.,VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | | | - David Anisman
- University of Utah School of Medicine, Salt Lake City
| | - Gerald Cochran
- University of Utah School of Medicine, Salt Lake City.,VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Gary Fischer
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Megan Hamm
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Ajay D Wasan
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Jia J, Linder JA. Default Nudges in Medicine-Designing the Right Choice. JAMA Netw Open 2022; 5:e222437. [PMID: 35297976 DOI: 10.1001/jamanetworkopen.2022.2437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jenny Jia
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Keller EJ, Nixon K, Oladini L, Chrisman HB, Chaudhari A, Milad MP, Vogelzang RL. The power of proximity: Effects of a multidisciplinary fibroid clinic on inter-specialty perceptions and practice patterns. PLoS One 2022; 17:e0263058. [PMID: 35077500 PMCID: PMC8789146 DOI: 10.1371/journal.pone.0263058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 01/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Multidisciplinary collaboration has generally been shown to have positive effects on healthcare but can be difficult to facilitate. This study assessed the effects of a multidisciplinary fibroid clinic on practice patterns and clinician perceptions to better understand drivers of interspecialty collaboration. Materials and methods Annual rates of hysterectomies, myomectomies, and uterine fibroid embolizations (UFEs) performed in an urban healthcare system were collected from 2012–2019. Rates of each procedure were compared over time before and after launching a multidisciplinary fibroid clinic at the academic medical center. Referral rates were also compared. The gynecologists and interventional radiologists (IRs) involved in the clinic were interviewed 2 years prior to and after the clinic launch about their approaches to fibroids and perceptions of others who treat this condition. A phenomenological approach was used to identify and compare themes within the interviews by two researchers with excellent inter-rater agreement (κ = 0.80). Results and discussion Annual rates of fibroid procedures increased over time (p<0.01) but the relative number of UFEs decreased (p = 0.01). UFE referrals by the clinic gynecologists significantly increased as did the number of combined fibroid procedures (p<0.01). However, the rates of one fibroid procedure relative to others were not different between the clinic and rest of the healthcare system (p = 0.55). Specialty-specific perceptions of fibroid treatments and inter-specialty dynamics did not change. Despite this, clinicians unanimously perceived the clinic and post-clinic practice patterns as positive and distinct from their previous work and relationships between gynecology and IR elsewhere. Limitations of this study included its single clinic design and potential confounder of differences in advertising pre- versus post-clinic. Conclusion Creating the right practice environment may be more important for fostering inter-specialty collaboration and work satisfaction than shared mental models or procedural volumes in certain practice settings.
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Affiliation(s)
- Eric J. Keller
- Division of Interventional Radiology, Stanford University, Stanford, CA, United States of America
- * E-mail:
| | - Kayla Nixon
- Division of Minimally Invasive Gynecologic Surgery, Northwestern University, Chicago, IL, United States of America
| | - Lola Oladini
- Division of Interventional Radiology, Stanford University, Stanford, CA, United States of America
| | - Howard B. Chrisman
- Division of Interventional Radiology, Northwestern University, Chicago, IL, United States of America
| | - Angela Chaudhari
- Division of Minimally Invasive Gynecologic Surgery, Northwestern University, Chicago, IL, United States of America
| | - Magdy P. Milad
- Division of Minimally Invasive Gynecologic Surgery, Northwestern University, Chicago, IL, United States of America
| | - Robert L. Vogelzang
- Division of Interventional Radiology, Northwestern University, Chicago, IL, United States of America
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Fernandez KA, Hamilton RH, Cabrera LY, Medaglia JD. Context-Dependent Risk & Benefit Sensitivity Mediate Judgments About Cognitive Enhancement. AJOB Neurosci 2022; 13:73-77. [PMID: 34931943 PMCID: PMC9867800 DOI: 10.1080/21507740.2021.2001077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Opinions about cognitive enhancement (CE) are context-dependent. Prior research has demonstrated that factors like peer pressure, the influence of authority figures, competition, moral relevance, familiarity with enhancement devices, expertise, and the domain of CE to be enhanced can influence opinions. The variability and malleability of patient, expert, and public attitudes toward CE is important to describe and predict because these attitudes can influence at-home, clinical, research, and regulatory decisions. If individual preferences vary, they could influence opinions about practices and regulations due to disagreements about the desirable levels of risks and benefits. The study of attitudes about CE would benefit from psychological theories that explain judgments. In particular, we suggest that variability in risk and benefit sensitivity could psychologically mediate judgments about CE in many contexts. Drawing from prospect theory, which originated in behavioral economics, it is likely that framing effects, shifted reference points, and the tendency to weigh losses (risks) more heavily than gains (benefits) predict decisions about CE. We suggest that public policy could benefit from a shared conceptual framework, such as prospect theory, that allows us to describe and predict real-world decisions about CE by patients, experts, and the public.
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Affiliation(s)
| | | | | | - John D. Medaglia
- Drexel University and Perelman School of Medicine, University of Pennsylvania
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Behavioral and Psychological Aspects of the Physician Experience with Deimplementation. Pediatr Qual Saf 2022; 7:e524. [PMID: 35071960 PMCID: PMC8782108 DOI: 10.1097/pq9.0000000000000524] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Deimplementation, or the structured elimination of non-evidence-based practices, faces challenges distinct from those associated with implementation efforts. These barriers may be related to intrinsic psychological factors, as perceptions and emotions surrounding the discontinuation of established practices appear to differ from those associated with practice adoption. This study aims to explore barriers and facilitators experienced by pediatric clinicians engaging in deimplementation projects. METHODS We used behavioral economics concepts to inform our qualitative study design following a theory-informed inductive approach. We conducted semistructured interviews with participants from two national quality improvement collaboratives where the primary outcomes were deimplementation measures. Using purposeful sampling, we recruited project leaders at institutions in the top and bottom quartiles from within each collaborative. Finally, we conducted a thematic analysis using a combination of inductive and deductive coding. RESULTS In total, we interviewed participants from 12 high-performing sites and 7 low-performing sites. Participants identified nine concepts associated with successful deimplementation practice and three psychological barriers that impacted behavior change: (1) loss, (2) fear, and (3) action bias. Participants further identified four overarching strategies for mitigating the identified psychological barriers, including (1) making allowance for nonconformism; (2) permission to change; (3) normalizing; and (4) reframing. CONCLUSION There is potential for more effective deimplementation through the proactive incorporation of an awareness of specific psychological barriers of loss, fear, and action bias, as well as specific mitigation strategies to address the psychocognitive experience.
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Ahmadi A, Sorensen A, Villaflores CWA, Mafi JN, Vangala SS, Hofer IS, Bartlett JD, Cheng EM, Duval VF, Damberg C, Elashoff D, Goldstein NJ, Ladapo JA, Moore JM, Pessegueiro AM, Shu SB, Skootsky SA, Turner A, Sarkisian CA. Protocol for pragmatic randomised trial: integrating electronic health record-based behavioural economic 'nudges' into the electronic health record to reduce preoperative testing for patients undergoing cataract surgery. BMJ Open 2021; 11:e049568. [PMID: 34732478 PMCID: PMC8572383 DOI: 10.1136/bmjopen-2021-049568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory. METHODS AND ANALYSIS This pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings. ETHICS AND DISSEMINATION The study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT04104256.
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Affiliation(s)
- Alast Ahmadi
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- Internal Medicine, University of California Irvine School of Medicine, Irvine, California, USA
| | - Andrea Sorensen
- Division of Geriatrics, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Chad Wes A Villaflores
- Division of Geriatrics, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Sitaram S Vangala
- Department of Medicine Statistics Core, Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Ira S Hofer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - John D Bartlett
- Department of Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Eric M Cheng
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Victor F Duval
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | | | - David Elashoff
- Department of Medicine Statistics Core, Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Noah J Goldstein
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- UCLA Anderson School of Management, Los Angeles, California, USA
| | - Joseph A Ladapo
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - James M Moore
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Antonio M Pessegueiro
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Suzanne B Shu
- SC Johnson College of Business at Cornell University, Ithaca, New York, USA
- The Charles H. Dyson School of Applied Economics and Management, Ithaca, New York, USA
| | - Samuel A Skootsky
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Ashley Turner
- Pharmacogenomics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Catherine A Sarkisian
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA
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Richards AR, Linder JA. Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review. Clin Ther 2021; 43:1654-1667. [PMID: 34702589 DOI: 10.1016/j.clinthera.2021.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Behavioral economics recognizes that contextual, psychological, social, and emotional factors powerfully influence decision-making. Behavioral economics has the potential to provide a better understanding of, and, through subtle environmental changes, or "nudges," improve persistent quality-of-care challenges, like ambulatory antibiotic overprescribing. Despite decades of admonitions and educational initiatives, in the United States, up to 50% of ambulatory antibiotic prescriptions remain inappropriate or not associated with a diagnosis. METHODS We conducted a Medline search and performed a narrative review that examined the use of behavioral economics to understand the rationale for, and improvement of, ambulatory antibiotic prescribing. FINDINGS Clinicians prescribe antibiotics inappropriately because of perceived patient demand, to maintain patient satisfaction, diagnostic uncertainty, or time pressure, among other reasons. Behavioral economics-informed approaches offer additional improvements in antibiotic prescribing beyond clinician education and communication training. Precommitment, in which clinicians publicize their intent to prescribe antibiotics "only when they are absolutely necessary," leverages clinicians' self-conception and a desire to act in a manner consistent with public statements. Precommitment was associated with a 20% absolute reduction in the inappropriate antibiotic prescribing for acute respiratory infections. Justification alerts, in which clinicians must provide a brief written rationale for prescribing antibiotics, leverages social accountability, redefines the status quo as an active choice, and helps clinicians to shift from fast to slow, careful thinking. With justification alerts, the absolute rate of inappropriate antibiotic prescribing decreased from 23% to 5%. Peer comparison, in which clinicians receive feedback comparing their performance to their top-performing peers, provides evidence of improved performance and leverages peoples' desire to conform to social norms. Peer comparison decreased absolute inappropriate antibiotic prescribing rates from 20% to 4%, a decrease that persisted for 12 months after the end of the intervention. Also, a one-time peer-comparison letter from a high-profile messenger to primary care practices with high rates of prescribing antibiotics, there was a 6-month, 3% decrease inantibiotic prescribing. Future directions in applying behavioral economics to the inappropriate antibiotic prescribing include paying careful attention to design details; improving intervention effectiveness and durability; making harms salient; participants' involvement in the development of interventions (the "Ikea effect"); factoring in patient satisfaction; and patient-facing nudges about antibiotic use and care-seeking. In addition, the COVID pandemic could aid in ambulatory antibiotic prescribing improvements due to changing cognitive frames around respiratory symptom evaluation and antibiotic prescribing. IMPLICATIONS To improve ambulatory antibiotic prescribing, several behavioral economics-informed approaches-especially precommitment, justification alerts, and peer comparison-have reduced the rates of inappropriate prescribing of antibiotics to low levels.
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Affiliation(s)
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Liang SY, Stults CD, Jones VG, Huang Q, Sutton J, Tennyson G, Chan AS. The Effects of Behavioral Economics-based Nudge on Online Scheduling and Appointment Completion: Observational Study (Preprint). JMIR Hum Factors 2021; 9:e34090. [PMID: 35353051 PMCID: PMC9008532 DOI: 10.2196/34090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/17/2021] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background Behavioral economics–based techniques have been an increasingly utilized method in health care to influence behavior change by modifying language in patient communication (through choice architecture and the framing of words). Patient portals are a key tool for facilitating patient engagement in their health, and interventions deployed via patient portals have been effective in improving utilization of preventive health services. Objective We examined the impacts of behavioral economics–based nudge health maintenance reminders on appointment scheduling through a patient portal and appointment completion for 2 preventive services: Medicare wellness visits and Pap smear. Methods We conducted a retrospective observational study using electronic health record data from an integrated health care system in Northern California. Nudge health maintenance reminders with behavioral economics–based language were implemented for all sites in November 2017 for Medicare wellness visits and for selected sites in February 2018 for Pap smears. We analyzed 125,369 health maintenance reminders for Medicare wellness visits, and 585,358 health maintenance reminders for Pap smear sent between January 2017 and February 2020. The primary outcomes were rate of appointments scheduled through the patient portal and appointment completion rate. We compared the outcomes between those who received the new, behavioral economics–based health maintenance reminders (the nudge group) and those who received the original, standard health maintenance reminders (the control group). We used segmented regression with interrupted time series to assess the immediate and gradual effect of the nudge for Medicare wellness visits, and we used logistic regression to assess the association of nudge health maintenance reminders, adjusting for the propensity to receive a nudge health maintenance reminder, for Pap smear. Results The rates of appointments scheduled through the patient portal were higher for nudge health maintenance reminder recipients than those for control health maintenance reminder recipients (Medicare wellness visits—nudge: 12,537/96,839, 13.0%; control: 2,769/28,530, 9.7%, P<.001; Pap smear—nudge: 8,239/287,149, 2.9%; control: 1,868/120,047, 1.6%; P<.001). Rates of appointment completion were higher for nudge health maintenance reminders for Pap smear (nudge: 67,399/287,149, 23.5% control: 20,393/120,047, 17.0%; P<.001) but were comparable for Medicare wellness visits (nudge: 49,835/96,839, 51.5% control: 14,781/28,530, 51.8%; P=.30). There was a marginally gradual effect of nudge on number of appointments scheduled through the patient portal for the overall Medicare wellness visits sample (at a monthly rate of 0.26%, P=.09), and a significant gradual effect among scheduled appointments (at a monthly rate of 0.46%, P=.04). For Pap smear, nudge health maintenance reminders were positively associated with number of appointments scheduled through the patient portal (overall sample: propensity adjusted odds ratio [OR] 1.62; 95% CI 1.50-1.74; among scheduled appointments: propensity adjusted OR 1.61, 95% CI 1.47-1.76) and with appointment completion (propensity adjusted OR 1.07; 1.04-1.10). Conclusions Nudges, a behavioral economics–based approach to providing health maintenance reminders, increased the number of appointments scheduled through the patient portal for Medicare wellness visits and Pap smear. Our study demonstrates that a simple approach—framing and modifying language in an electronic message—can have a significant and long-term impact on patient engagement and access to care.
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Affiliation(s)
- Su-Ying Liang
- Sutter Health Center for Health Systems Research, Palo Alto, CA, United States
| | - Cheryl D Stults
- Sutter Health Center for Health Systems Research, Palo Alto, CA, United States
| | - Veena G Jones
- Clinical Leadership Team, Sutter Health, Sacramento, CA, United States
| | - Qiwen Huang
- Sutter Health Center for Health Systems Research, Palo Alto, CA, United States
| | - Jeremy Sutton
- Clinical Leadership Team, Sutter Health, Sacramento, CA, United States
| | - Guy Tennyson
- Clinical Leadership Team, Sutter Health, Sacramento, CA, United States
| | - Albert S Chan
- Clinical Leadership Team, Sutter Health, Sacramento, CA, United States
- Center for Biomedical Informatics Research, Stanford University, Stanford, CA, United States
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Abstract
OBJECTIVE Nudges are interventions that alter the way options are presented, enabling individuals to more easily select the best option. Health systems and researchers have tested nudges to shape clinician decision-making with the aim of improving healthcare service delivery. We aimed to systematically study the use and effectiveness of nudges designed to improve clinicians' decisions in healthcare settings. DESIGN A systematic review was conducted to collect and consolidate results from studies testing nudges and to determine whether nudges directed at improving clinical decisions in healthcare settings across clinician types were effective. We systematically searched seven databases (EBSCO MegaFILE, EconLit, Embase, PsycINFO, PubMed, Scopus and Web of Science) and used a snowball sampling technique to identify peer-reviewed published studies available between 1 January 1984 and 22 April 2020. Eligible studies were critically appraised and narratively synthesised. We categorised nudges according to a taxonomy derived from the Nuffield Council on Bioethics. Included studies were appraised using the Cochrane Risk of Bias Assessment Tool. RESULTS We screened 3608 studies and 39 studies met our criteria. The majority of the studies (90%) were conducted in the USA and 36% were randomised controlled trials. The most commonly studied nudge intervention (46%) framed information for clinicians, often through peer comparison feedback. Nudges that guided clinical decisions through default options or by enabling choice were also frequently studied (31%). Information framing, default and enabling choice nudges showed promise, whereas the effectiveness of other nudge types was mixed. Given the inclusion of non-experimental designs, only a small portion of studies were at minimal risk of bias (33%) across all Cochrane criteria. CONCLUSIONS Nudges that frame information, change default options or enable choice are frequently studied and show promise in improving clinical decision-making. Future work should examine how nudges compare to non-nudge interventions (eg, policy interventions) in improving healthcare.
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Affiliation(s)
- Briana S Last
- Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alison M Buttenheim
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carter E Timon
- College of Liberal and Professional Studies, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rinad S Beidas
- Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Peer Comparisons to Increase Responsible Opioid Prescribing Among Oral and Maxillofacial Surgeons. J Oral Maxillofac Surg 2020; 79:955-957. [PMID: 33428865 DOI: 10.1016/j.joms.2020.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 11/22/2022]
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