Abstract
BackgroundCurrent guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden.MethodsWe will apply a systematic, user-centered design approach to incorporate BE “nudges” into a CDS module and will perform user testing in two “vanguard” sites. To accomplish this, we will conduct (1) semi-structured interviews with key informants (n = 8), (2) a 2-h, design-thinking workshop to derive and refine initial module ideas, and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics.DiscussionWe hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases.
Highlights
Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes
Shorter life expectancy Non-metformin agent. The goal of these analyses is to identify key barriers and facilitators, as well as any emerging themes related to the use of the behavioral economics (BE)-electronic health record (EHR) module to influence provider adherence to the Choosing Wisely (CW) guidelines
Novelty of combining behavioral economics with clinical decision support tools The incorporation of behavioral economic principles into EHR clinical decision support tools shows promise as a strategy to improve guideline adherence by addressing stubborn barriers, such as alert fatigue, that prevent the CDS from having a desired impact on clinician behavior
Summary
Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. A number of randomized controlled trials, including the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial [1], the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial [2], and the Veterans Affairs Diabetes Trial (VADT) [3], found that intensive glycemic control was not protective for macrovascular complications of diabetes including myocardial infarction or stroke These trials demonstrate the potential for harm with tight glycemic control, notably increased risk of hypoglycemia [4], and a suggestion of increased all-cause mortality [1]. Reasonable targets include an HbA1c of 7.0–7.5% in healthy, older adults with long life expectancy; 7.5–8.0% for patients with moderate comorbidity and a life expectancy of less than 10 years; and 8.0–9.0% for patients with multiple comorbid conditions and a shorter life expectancy [4, 12]
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