Behavioral Economics Applications to Geriatrics Leveraging EHRs R33 Trial

Study Overview
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Brief Summary
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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
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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.

Official Title
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Behavioral Economics Applications to Geriatrics Leveraging EHRs R33 Trial

Conditions
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Asymptomatic Bacteriuria, Prostate Specific Antigen Screening, Type 2 Diabetes

Intervention / Treatment
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* Behavioral: EHR clinical decision support nudges
* Behavioral: Brief clinician education


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Northwestern Medicine primary care clinician who sees patients under department code of a randomized clinic Exclusion Criteria: Resident physicians will be excluded Clinicians who participated in pilot study of these interventions Clinician study investigators

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Cluster-randomized by primary care clinic using a constrained randomization process.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Brief clinician education<br>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. | Behavioral: Brief clinician education<br>* Clinicians will be invited to view brief education material.<br>|
| Experimental: Clinical decision support nudges and brief clinician education<br>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. | Behavioral: EHR clinical decision support nudges<br>* Clinical decision support nudges delivered within the EHR when conditions meet alert triggering criteria.<br>Behavioral: Brief clinician education<br>* Clinicians will be invited to view brief education material.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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. | 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. | 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. | 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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. | 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 | 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. | 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. | 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. | 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 | 18 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Geriatrics, Quality of care