Behavioral Economics Applications to Geriatrics Leveraging EHRs R33 Trial

Not Applicable

Completed

• Conditions: Asymptomatic Bacteriuria; Prostate Specific Antigen Screening; Type 2 Diabetes
• Interventions: Behavioral: EHR clinical decision support nudges; Behavioral: Brief clinician education

• Registration Number: NCT04289753
• Lead Sponsor: Northwestern University

Brief Summary

Investigators will evaluate clinical decision support nudges informed by behavioral science and directed at primary care clinicians. These will be used to reduce commonly misused, and potentially harmful, diagnostic and therapeutic actions that occur in the care of older adults (e.g. overtreatment of type 2 diabetes, misuse of PSA screening, misuse of urine testing in women with nonspecific symptoms or no symptoms.

Detailed Description

Diagnostic and therapeutic strategies misapplied to older adults can lead to increased morbidity and mortality. Despite recommendations from the American Geriatrics Society for the Choosing Wisely Initiative, there are clear examples where clinicians do not often follow best practices leading to patient harm. These include: (1) testing and treatment for asymptomatic bacteriuria (ASB) in older women, (2) prostate specific antigen (PSA) screening in older men, and (3) aggressive treatment with insulin or oral hypoglycemics for type 2 diabetes.

Clinical decision support nudges, informed by behavioral economics and social psychology and delivered via electronic health records (EHRs), are promising strategies to reduce the misuse of services. Behavioral economics-informed interventions influence conscious and unconscious drivers of decision making, are low cost, and can be incorporated into existing systems.

This randomized controlled trial will evaluate the effects of three clinical decision support nudges on three clinical quality measures, indicators of patient safety, and clinician attitudes.

Basic Information
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Recruitment & Eligibility
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Study & Design
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Trial Locations

Study Timeline

• Study First Submitted: 2020-02-26
• Study First Submitted QC: 2020-02-27
• Study First Posted: 2020-02-28
• Study Start: 2020-09-01
• Primary Completion: 2022-03-01
• Study Completion: 2022-09-30
• Results First Submitted: 2023-06-01
• Status Verified: 2023-07
• Results First Submitted QC: 2023-07-24
• Last Update Submitted: 2023-07-24
• Results First Posted: 2023-08-16
• Last Update Posted: 2023-08-16

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 37134

Inclusion Criteria

• Northwestern Medicine primary care clinician who sees patients under department code of a randomized clinic

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Exclusion Criteria

• Resident physicians will be excluded
• Clinicians who participated in pilot study of these interventions
• Clinician study investigators

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Clinical decision support nudges and brief clinician education	EHR clinical decision support nudges	Clinicians attributed to clinics randomized to the clinical decision support nudges and brief clinician decision support arm will receive clinical decision support within the EHR when conditions meet alert triggering criteria. These clinicians will also receive invitation to view an online educational module and be recruited to complete an online survey at baseline and 18 months.
Brief clinician education	Brief clinician education	Clinicians attributed to clinics in the brief clinician education arm will receive invitation to view an online educational module and be recruited to complete an online survey at baseline and 18 months.
Clinical decision support nudges and brief clinician education	Brief clinician education	Clinicians attributed to clinics randomized to the clinical decision support nudges and brief clinician decision support arm will receive clinical decision support within the EHR when conditions meet alert triggering criteria. These clinicians will also receive invitation to view an online educational module and be recruited to complete an online survey at baseline and 18 months.

Primary Outcome Measures

Name	Time	Method
Diabetes Overtreatment in the Elderly	18 months	Measure defined as having the most recent hemoglobin A1C during the measurement period of less than 7.0 and insulin or an oral hypoglycemic drug on their active medication list at the end of the measurement period among adults aged 75 years and older with a diagnosis of diabetes mellitus.
PSA Screening in Older Men	18 months	Measure defined as the presence of a PSA laboratory result in the EHR during the measurement period among men aged 76 years and older at the start of the measurement period with at least one visit during the measurement period with a primary care clinician and who are without a diagnosis or procedure suggesting a history of prostate cancer.
Urine Testing for Non-specific Reasons	18 months	Measure defined as the absence of a diagnostic code for a specific genitourinary sign, symptoms or other potentially relevant indication among instances where a urinalysis and/or urine culture is obtained in the interval 24 hours before to 48 hours after a face-to-face ambulatory care visit by a woman aged 65 years or older with a primary care clinician during the measurement period.

Secondary Outcome Measures

Name	Time	Method
Rate of Poor Diabetes Control Among Previously Tightly Controlled	18 months	Occurrence of HbA1c \>9.0 among patients who previously had a HbA1c \<7.0 and met the criteria for treatment deintensification intervention and had one or more outpatient primary care encounters during the study period.
Rate of Hyperglycemia Requiring Hospital Care Following Clinical Decision Support Exposure	18 months	Emergency department visit or hospitalization for hyperglycemia within 90 days of an index visit where the clinician was exposed to the diabetes decision support.
Rate of UTI Requiring Hospital Care Among Women 65 and Over Following Clinical Decision Support Exposure	18 months	Emergency department visit or hospitalization for an infection originating from the urinary tract within 28 days of any primary care office visit with decision support exposure.
Rate of UTI Requiring Hospital Care Among Women 65 and Over Following an Office Visit	18 months	Emergency department visit or hospitalization for an infection originating from the urinary tract within 28 days of any primary care office visit
Rate of Hypoglycemia Requiring Urgent Care Among Previously Tightly Controlled	18 months	Emergency department visit or hospitalization for hypoglycemia among patients who previously had a HbA1c \<7.0 and met the criteria for treatment deintensification intervention and had one or more outpatient primary care encounters during the study period
Rate of Hyperglycemia Requiring Hospital Care Among Previously Tightly Controlled	18 months	Emergency department visit or hospitalization for hyperglycemia among patients who previously had a HbA1c \<7.0 and met the criteria for treatment deintensification intervention and had one or more outpatient primary care encounters during the study period.

Trial Locations

Locations (1)

Northwestern Medicine; 🇺🇸 Chicago, Illinois, United States