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Patient Safety World
January 2023
A Nudge in Time
Nudges, when provided correctly, can often be an effective means to help achieve desirable outcomes. We’ve given several examples in the columns noted below.
Researchers at Penn Medicine recently demonstrated successful use of EHR-delivered nudges to improve prescribing statins to patients where statin therapy was indicated. Because statins are often underutilized in patients who may benefit from them, Adusumalli and colleagues (Adusumalli 2022) performed a cluster randomized clinical trial of 4131 patients from 28 primary care practices affiliated with Penn Medicine who met criteria for statin use in guidelines. Nudges were provided to primary care clinicians, patients, or both and results were compared with groups having no nudges. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message delivered 4 days before the visit. The combined nudge included the clinician and patient nudges.
During the intervention, statins were prescribed to 7.3% of patients in the usual care group, 8.5%, in the patient nudge group, 13.0% in the clinician nudge arm, and 15.5% in the combined group. So, the clinician nudge improved statin prescribing and the combined nudge (clinician and patient) was even more successful. But the patient nudge alone did not improve statin prescribing. Prescribing rates improved in the clinician-only and clinician -plus-patient nudge groups compared with usual care, by 5.5 and 7.2 absolute percentage points, respectively.
But success was likely due to more than just the targets of the nudges. The timing and content were important. Rather than presenting the nudge when the clinician logged on to the EHR, the nudge appeared when the clinician went to the ordering page of an eligible patient. And it was presented with a calculation of the patient’s risk and a chart with statin dosing options. That made it easier for the clinician to order a statin without an interruption in workflow. The timing of the patient nudge may also have been important. It was delivered via text message starting 4 days before their appointment, reminding them of the upcoming appointment and informing them of an important message about their heart health. Patients had to reply to confirm their willingness to communicate by text, and if so, they were told that “guidelines indicate you should be taking a statin to reduce the chance of a heart attack” and about the benefits of lowering cholesterol and the rare adverse effects that go away upon stopping the medication. Patients were told that “at Penn Medicine, it is standard of care to prescribe a statin to patients like you.” Patients were asked to reply “Y” if they were interested in taking a statin or reply “?” if they were unsure or had questions for the physician. Patients replying “Y” were told to remember to discuss the statin during their visit and sent a link to a shared decision-making tool on statin therapy. While nudging the patient alone did not improve statin prescribing, it probably set the stage for appropriate discussion with those clinicians who also were nudged.
One other likely success factor was that the active choice prompt in the EHR to clinicians was codesigned by leadership and frontline clinicians in the health system.
We like this nudge. Although the improvements might seem modest, the accompanying editorial (Ahmad 2022) notes that this occurred against a background high baseline prescription rate of statins in the statin-eligible population (approximately 70%) and the majority of untreated patients were candidates for primary, not secondary, prevention, making this group of patients particularly challenging for seeing large effect sizes of interventions.
See some of our other columns dealing with “nudges”:
- July 7, 2009 “Nudge: Small Changes, Big Impact”
- February 18, 2018 “Nudged, But Who Nudged Who?”
- June 19, 2018 “More EHR-Related Problems”
- April 30, 2019 “Reducing Unnecessary Urine Cultures”
- July 23, 2019 “Order Sets Can Nudge
the Right Way or the Wrong Way”
- February 18, 2020 “More Nudges”
References:
Adusumalli S, Kanter GP, Small DS, et al. Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial. JAMA Cardiol 2022; Published online November 30, 2022
https://jamanetwork.com/journals/jamacardiology/fullarticle/2798971
Ahmad FS, Persell SD. Nudging to Improve Cardiovascular Care—Clinicians, Patients, or Both. JAMA Cardiol 2022; Published online November 30, 2022
https://jamanetwork.com/journals/jamacardiology/article-abstract/2798974
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