High-risk polypharmacy is common among older adults in the United States, is particularly dangerous for individuals with dementia or cognitive impairment, and is associated with harms such as adverse drug reactions, falls, and higher costs of care. This project aims to test in a pragmatic clinic-randomized controlled trial two electronic health record-based behavioral economic nudges to help clinicians reduce high-risk polypharmacy among their older adult patients and in the subgroup with dementia or cognitive impairment. The main questions this trial aims to answer are: Aim 1: To evaluate the effects of an EHR-based commitment nudge, a justification nudge, and the combination of both nudges on a composite measure of high-risk polypharmacy via a pragmatic randomized controlled trial. The investigators will use cluster randomization in which primary care clinics are randomized to receive 0, 1, or 2 nudges using a factorial design. The nudges will run for 18 months, followed by 12 months of observation to assess persistence of effects. Aim 2: To qualitatively and quantitatively assess clinician experiences with the EHR-based nudges, including their acceptability and effects on workflow. At the conclusion of the intervention period, the investigators will perform semi-structured interviews and field a clinician survey.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE
Enrollment
786
EHR clinical decision support alerts-clinician commitment to discuss high risk polypharmacy
Brief, online education module for primary care clinicians
EHR clinical decision support alerts-clinician rational for high risk polypharmacy
Northwestern Medicine
Chicago, Illinois, United States
UPMC
Pittsburgh, Pennsylvania, United States
The percentage of HRPP with any (1 or more) of the 7 measures of high risk polypharmacy. (Composite measure)
The composite of the 7 high-risk polypharmacy measures (Secondary outcomes #6-12)
Time frame: 18 months
The rate of Emergency Department visits per patient -all cause
Denominator: All older adults with HRPP. Numerator: Patients with an emergency department encounter during the look back period.
Time frame: 18 months
The rate of Emergency Department visits per patient-Adverse drug event (ADE)-specific
Denominator: All older adults with HRPP. Numerator: Patients with an emergency department encounter for ADE during the look back period.
Time frame: 18 months
The rate of hospital admissions per patient-all cause
Denominator: All older adults with HRPP. Numerator: Patients with an inpatient admission for any reason during the look back period.
Time frame: 18 months
The rate of hospital admissions per patient-ADE-specific
Denominator: All older adults with HRPP. Numerator: Patients with an inpatient admission for ADE during the look back period.
Time frame: 18 months
The percentage of HRPP patients with a fall condition-drug interaction
Denominator: All older adult patients with HRPP with a fall marker. Numerator: Patients with an active eligible fall risk medication on medication list.
Time frame: 18 months
The percentage of HRPP patients with a fall drug-drug interaction
Denominator: All older adult patients with HRPP. Numerator: Patients with greater than or equal to 3 active eligible fall risk medications.
Time frame: 18 months
The percentage of HRPP patients with Heart failure-NSAID interaction
Denominator: All older adult patients with HRPP with a CHF marker. Numerator: Patients with an active eligible NSAID medication.
Time frame: 18 months
The percentage of HRPP patients with Heart Failure-thiazolidinedione interaction
Denominator: All older adults with HRPP with a CHF marker. Numerator: Patients with an active eligible thiazolidinedione medication.
Time frame: 18 months
The percentage of HRPP patients with Heart failure with reduced ejection fraction- non-dihydropyridine calcium channel blocker interaction
Denominator: All older adults with HRPP with CHFlowEF marker. Numerator: Patients with an active eligible calcium channel blocker medication.
Time frame: 18 months
The percentage of HRPP patients with CKD-glyburide/glimepiride interaction
Denominator: All older adults with HRPP with most-recent eGFR \<60. Numerator: Patients with an active eligible glyburide-containing medication.
Time frame: 18 months
The percentage of HRPP patients with CKD-NSAID interaction
Denominator: All older adults with HRPP with most-recent eGFR \< 30. Numerator: Patients with an active eligible NSAID medication.
Time frame: 18 months
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