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.
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.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE
Enrollment
37,134
Clinical decision support nudges delivered within the EHR when conditions meet alert triggering criteria.
Clinicians will be invited to view brief education material.
Northwestern Medicine
Chicago, Illinois, United States
PSA Screening in Older Men
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.
Time frame: 18 months
Urine Testing for Non-specific Reasons
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.
Time frame: 18 months
Diabetes Overtreatment in the Elderly
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.
Time frame: 18 months
Rate of UTI Requiring Hospital Care Among Women 65 and Over Following Clinical Decision Support Exposure
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.
Time frame: 18 months
Rate of UTI Requiring Hospital Care Among Women 65 and Over Following an Office Visit
Emergency department visit or hospitalization for an infection originating from the urinary tract within 28 days of any primary care office visit
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Time frame: 18 months
Rate of Hyperglycemia Requiring Hospital Care Following Clinical Decision Support Exposure
Emergency department visit or hospitalization for hyperglycemia within 90 days of an index visit where the clinician was exposed to the diabetes decision support.
Time frame: 18 months
Rate of Hyperglycemia Requiring Hospital Care Among Previously Tightly Controlled
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.
Time frame: 18 months
Rate of Poor Diabetes Control Among Previously Tightly Controlled
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.
Time frame: 18 months
Rate of Hypoglycemia Requiring Urgent Care Among Previously Tightly Controlled
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
Time frame: 18 months