Effectiveness Of Nudges Research Articles

Electronic nudge letters to increase influenza vaccination uptake in younger and middle-aged individuals with diabetes: a prespecified analysis of the NUDGE-FLU-CHRONIC trial

Abstract Background Despite evidence demonstrating that influenza vaccination is associated with reduced risk of adverse cardiovascular events and all-cause mortality, influenza vaccine uptake remains suboptimal in persons with diabetes mellitus (DM). Purpose In this prespecified analysis of the NUDGE-FLU-CHRONIC trial we assessed the effectiveness of electronically delivered nudges on influenza vaccine uptake according to DM status. Methods NUDGE-FLU-CHRONIC was a nationwide, randomized, pragmatic implementation trial among younger and middle-aged (18-64 years) Danish citizens with chronic disease during the 2023/2024 influenza season. All trial participants were eligible for a free influenza vaccination through the Danish governmental vaccine program. Participants were randomized in a 2.45:1:1:1:1:1:1 ratio to usual care (no electronic letter) or one of 6 different electronic nudge letters delivered on Sep 26, 2023. Baseline and outcome data were obtained using the Danish nationwide registries. The endpoint was receipt of a seasonal influenza vaccine on or before Jan 1, 2024. Results Of 299,881 NUDGE-FLU-CHRONIC participants, 57,666 (19.2%) had DM at baseline. Participants with DM had a median age of 51.6 years, 43.0% were female, median Hba1c of 53 mmol/mol, median DM duration of 10.0 years, and 51.2% were insulin dependent. During follow-up, 43.0% of those with DM vs. 34.6% of those without DM received the seasonal influenza vaccine (p<0.001). Any electronic letter vs. usual care was highly effective in increasing vaccine uptake in participants with DM at baseline (45.6% vs. 36.5%, difference: +9.1 percentage points [99.29%CI: 7.9-10.3], relative risk ratio [RR]: 1.42, 99.29%CI: [1.39-1.44]). However, DM status modified the effect of any electronic letter such that participants without DM at baseline experienced a slightly greater effect than those with DM (37.3% vs. 25.9%, difference: +12.3 percentage points [11.7-12.8], RR: 1.47 [1.45-1.50]; p-interaction <0.001). For each individual electronic nudge letter, the effect of the intervention was slightly lower in participants with DM compared to those without (Figure 1; all p-interaction < 0.015). When assessing DM subgroups, the effect of any electronic letter vs. usual care was greater in participants with DM and concomitant cardiovascular disease than in those without, greater in non-insulin treated than in insulin-treated individuals, and greater in those with shorter diabetes duration. Effectiveness of nudges were consistent across all other DM subgroups including HbA1c level (Figure 2). Conclusions Electronic nudge letters significantly boosted vaccine uptake in a broad range of individuals with DM, but the effect was slightly lower compared to those without DM. Future studies should test whether behaviorally designed nudges may positively influence other health behaviors in people with diabetes.

Electronic nudges to increase influenza vaccination in patients with chronic kidney disease: a prespecified analysis of NUDGE-FLU-CHRONIC

Abstract Background Annual influenza vaccination is recommended for individuals with chronic kidney disease (CKD); however, guideline adherence is suboptimal potentially related to lack of awareness of vaccine availability and effectiveness. Purpose This prespecified analysis of the NUDGE-FLU-CHRONIC trial investigated the effectiveness of digital behavioral nudges on influenza vaccine uptake based on the presence or absence of CKD. Methods NUDGE-FLU-CHRONIC was a randomized, nationwide trial, conducted during the 2023/2024 influenza season including younger and middle-aged (18-64 years) Danish citizens with chronic illnesses (making them eligible for the free Danish vaccine program). Participants were randomized in a ratio of 2.45:1:1:1:1:1:1 to receive either usual care (no letter) or one of six different letter-based nudges, delivered via the governmental electronic letter system on September 26, 2023. Baseline and outcome data were obtained with the Danish nationwide registers. Primary endpoint was receipt of an influenza vaccine no later than January 1, 2024. Results A total of 299,881 individuals were randomized in NUDGE-FLU-CHRONIC trial, among them, 15,208 (5.1%) had a history of CKD. Participants with CKD had a median age was 53.1 years (IQR, 42.2-59.6) and 46.0% were female. During follow-up, 43.7% of participants with CKD were vaccinated compared with 35.8% of participants without CKD (p<0.001). Any letter was highly effective in increasing influenza vaccination in the overall population but was slightly less effective in those with a history of CKD (p for interaction = 0.005). In participants with CKD, any letter increased vaccination by 25% versus no letter (46.3% vs. 37.1%; difference, 9.3 percentage points; 99.29%CI, 6.9-11.6; RR, 1.25; 99.29%CI, 1.18-1.33). In participants without CKD, any letter increased vaccination by 43% (39.2% vs. 27.4%; difference, 11.8 percentage points; 99.29%CI, 11.3-12.3; RR, 1.43; 99.29%CI, 1.41-1.45). Similar patterns were observed when assessing each intervention letter individually (Figure 1). Effectiveness of any letter vs. usual care was consistent across CKD subgroups, except for concomitant diabetes vs no diabetes (Figure 2). There was no observed effect modification by CKD duration (p for interaction = 0.78) or by estimated glomerular filtration rate (p for interaction = 0.78) modelled continuously for any letter vs. usual care. Conclusion In this prespecified analysis from the nationwide NUDGE-FLU-CHRONIC trial, only approximately 1 in 3 younger and middle-aged adults with CKD received influenza vaccination. Digital nudge letters emphasizing the importance of annual influenza vaccination significantly boosted rates of vaccination across a broad range of individuals with CKD.Figure 1Figure 2

Estimating Contribution Quality in Online Deliberations Using a Large Language Model

Deliberation involves participants exchanging knowledge, arguments, and perspectives and has been shown to be effective at addressing polarization. The Stanford Online Deliberation Platform facilitates large-scale deliberations. It enables video-based online discussions on a structured agenda for small groups without requiring human moderators. This paper's data comes from various deliberation events, including one conducted in collaboration with Meta in 32 countries, and another with 38 post-secondary institutions in the US. Estimating the quality of contributions in a conversation is crucial for assessing feature and intervention impacts. Traditionally, this is done by human annotators, which is time-consuming and costly. We use a large language model (LLM) alongside eight human annotators to rate contributions based on justification, novelty, expansion of the conversation, and potential for further expansion, with scores ranging from 1 to 5. Annotators also provide brief justifications for their ratings. Using the average rating from other human annotators as the ground truth, we find the model outperforms individual human annotators. While pairs of human annotators outperform the model in rating justification and groups of three outperform it on all four metrics, the model remains competitive. We illustrate the usefulness of the automated quality rating by assessing the effect of nudges on the quality of deliberation. We first observe that individual nudges after prolonged inactivity are highly effective, increasing the likelihood of the individual requesting to speak in the next 30 seconds by 65%. Using our automated quality estimation, we show that the quality ratings for statements prompted by nudging are similar to those made without nudging, signifying that nudging leads to more ideas being generated in the conversation without losing overall quality.

Examining the effectiveness of promotional nudges increasing plant-based food choices in a post-secondary education dining hall: a pilot study.

To evaluate nudge strategies that increase the consumption of plant-based foods, defined as vegetarian or vegan food items, compared with meat-based options in post-secondary dining hall settings. A pilot study. This study took place in the University of British Columbia Vancouver Campus's Gather Dining Hall (GDH) over a 6-week intervention period and two control periods. The intervention incorporated several nudges (proportion increases, item placement, taste-focused labelling, Chef's featured special verbal prompts, social media and promotional posters) into the menu and dining hall area with the goal of increasing the purchases of plant-based items. Sales data from meals that were purchased during the intervention period were compared with sales data from the two control periods. Students and staff who purchased meals in the GDH. The proportion of plant-based items sold significantly increased during the intervention period (56·7 %; P < 0·01) compared with the last 6 weeks of term one (53·6 %) and the first 6 weeks of term two (53·4 %). The proportion of plant-based 'main' menu items was significantly higher in the intervention period (46·4; P < 0·01) when compared with the last 6 weeks of term one (40·9 %) and the first 6 weeks of term two (41·7 %). The combination of nudges was effective at significantly increasing the selection of plant-based options over meat-based options in a post-secondary dining hall setting.

An exploratory research on bioplastic use in Nigeria: employing a green nudge approach

Bioplastics serve as good alternatives to conventional plastics, but their production and adoption globally remain generally low. This paper sought to determine the consumer preference for bioplastics due to the urgent need for an invention on plastic pollution in Nigeria. This was achieved by employing green nudges on consumers' choice experiments on bioplastic products. The study used a sample size of 327 respondents employing the snowball sampling approach. We discovered that there was high preference heterogeneity among respondents probably due to cultural diversity and attitudinal differences. Moreover, respondents preferred to stick with their preferences instead of opting for a change in their decisions. This may have been because Nigerians are known to be brand loyalists. Our results showed that the Text treatment group thought that bioplastic labels were innovative and useful compared to the control group. This perception was probably because of the concise text on the advantages of bioplastics. We conclude that although respondents were exposed to various green nudges, there was little effect of the green nudges on their purchasing decisions. We recommend that further studies be carried out to understand why price effect was not effective in Nigeria against theory and as compared to developed countries.

Nudging consumers’ choices for niche milk: A real purchase experiment

Changing behaviours causing poor health is an ongoing global health challenge that requires developing adequate food policies and strengthening their effectiveness. Policies based on nudging have become increasingly popular internationally, but the literature provides mixed evidence of their effectiveness, with an intense academic debate. This study contributes to the debate by investigating the effect of different nudging techniques (availability enhancement, visibility enhancement and healthy eating calls) via a framed field experiment involving purchases of milk types. Participants were split into different nudging treatment groups and were endowed with a cash amount to purchase any desired quantity of the different products. We modelled observed choices via the multiple discrete–continuous nested extreme value model, which has yet to receive attention for the analysis of nudging effects on food choices. Results show that only the healthy eating call nudge effectively drove participants towards healthier milk choices, while the effect of other nudges is statistically insignificant. We provide simulated demand curves conditional on nudging treatments, which measure the effect of the latter on consumers’ consumption levels of the different milk types available.

Frail Older Adults' Needs and Preferences for Mobile Health Exercise Interventions Guided by Nudge Theory: AQualitative Analysis.

To explore frail older adults' preferences and needs regarding mobile health (mHealth) exercise interventions in China. Additionally, it sought to identify the nudge strategies necessary for initiating and sustaining exercise behaviours among frail older adults. A qualitative study. The semi-structured interviews were conducted between April and May 2024 from two communities in Changsha, China. The data were analysed using a deductive framework analysis aligned to nudge theory, and an inductive thematic analysis to gather relevant needs and preferences. This study involved 14 participants with pre-frailty or frailty, aged 60-82 years (median age of 64 years). While participants were generally receptive to new technologies, lower levels of health literacy and competing priorities often hindered their participation. Three primary functionality requirements were as follows. (1) Profession engagement: tailored exercise prescription, professional and timely feedback and guidance; (2) personalised knowledge encompassing pain management, successful cases and inspiration; (3) beneficial, tailored, dynamic, fragmented, challenging exercise courses. Participants showed positive attitudes towards simplification nudges, gamification nudges, social nudges, trustworthy nudges, reminder nudges, economic nudges, feedback nudges and pre-commitment nudges. Addressing privacy concerns was essential to build trust and acceptance among older adults. These findings emphasised the importance of designing mHealth interventions that address frail older adults' specific needs and preferences while incorporating effective nudge strategies to promote engagement and adherence. Future researchers should explore wearables, ChatGPT language models, virtual coaching assistants, exercise snack to further optimise the experience and analyse the effects of nudges in mHealth exercise interventions among older adults. Exercise systems or app development for frail older adults should meet three basic functionality and essential nudge strategies. The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting. Older adults' engagement and interview data contribute a lot.

The Impact of Default Options on Tourist Intention Post Tourism Chatbot Failure: The Role of Service Recovery and Emoticon

Chatbot service failures are inevitable in tourism and hospitality, how chatbot service recovery retains tourists is an issue that cannot be ignored. The nudging effect of default options on consumers' behavior has been demonstrated in marketing. Whether default options can be as a powerful tool for service failure recovery is underexplored. Thus, this study aims to explore whether the default option can improve tourists' willingness to continue using the chatbot after service failure. Hypotheses were tested using three experiments, results showed that the opt-out default option can increase higher tourists' continuous use intention by decreasing tourists' affective effort. This effect is moderated by service recovery and emoticon. Specifically, opt-out default option is more effective to improve continuous usage intention when using informational help and pleading emoticon. These findings enriched theories on chatbot service failure and recovery and provide insight for default options using in chatbot under tourism and hospitality industry.

Let us go with the flow − Impact of a dynamic social norm nudge on parents’ school menu selection

Designing more sustainable school meal offerings not only contributes to environmental protection and climate change mitigation but also promotes children’s health, provides food education, and raises awareness on sustainability issues. The present study, using a between-subject experimental online survey (N = 617), proved the effectiveness of a dynamic social norm nudge in encouraging parents to make more environmentally friendly choices when selecting school menus for their elementary school children. In addition, nudging was more successful in promoting sustainable food choices among parents with lower levels of education and those who are more actively involved and responsible for child-related practices. Disentangling the individual traits that leverage the effectiveness of nudges should allow public entities to fully exploit the potential of these interventions and design tailored approaches for targeted subpopulations.

The effects of nudging and pricing strategies on the availability and purchases of ultra-processed foods: A secondary analysis of the Supreme Nudge trial

Regular consumption of ultra-processed foods (UPF) is a risk factor for morbidity and mortality. UPF are widely available in supermarkets. Nudging and pricing strategies are promising strategies to promote healthier supermarket purchases and may reduce UPF purchases. We investigated whether supermarket nudging and pricing strategies targeting healthy foods, but not specifically discouraging UPF, would change UPF availability, price, promotion and placement (UPF-APPP) in supermarkets and customer UPF purchases. We used data from the Supreme Nudge parallel cluster-randomized controlled trial, testing the effect of a combined nudging and pricing intervention promoting healthy products. The Dutch Consumer Food Environment Score (D-CFES) was used to audit 12 participating supermarkets in terms of UPF-APPP. We used customer loyalty card data of the first twelve intervention weeks from 321 participants to calculate the proportion of UPF purchases. Descriptive statistics were used to assess differences in D-CFES between supermarkets. Mixed model analyses were used to assess the association between the D-CFES and UPF purchases and the effect of the intervention on UPF purchases. No difference in the D-CFES between intervention and control supermarkets were found. No statistically significant association between the D-CFES and UPF purchases (β = −0.00, 95%CI: −0.02, 0.01) and no significant effect of the intervention on UPF purchases (β = 0.02, 95%CI: −0.07, 0.12) was observed. Given the significant proportion of unhealthy and UPF products in Dutch supermarkets, nudging and pricing strategies aimed at promoting healthy food purchases are not sufficient for reducing UPF–APPP nor purchases, and nationwide regulation may be needed.Trial registration number: Dutch Trial Register ID NL7064, May 30, 2018, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7302.

Boosting Nudging Effects by Messenger Impression to Promote Carbon Recycling Technologies [Conference Presentation Abstract

Boosting Nudging Effects by Messenger Impression to Promote Carbon Recycling Technologies [Conference Presentation Abstract

Nudging against consent is effective but lowers welfare

Behavioural nudges are often criticised because they “work best in the dark”. However, recent experimental evidence suggests that the effectiveness of nudges is not reduced when they are delivered transparently. Most people also endorse transparent nudges. Yet, transparent nudging may undermine human autonomy—a minority may oppose to being nudged and feel manipulated, even if they know what is happening. We propose an alternative way of maintaining autonomy that is not reducible to transparency: individuals can be asked if they consent in advance to being nudged. To assess whether consensual nudges are effective, we ask consent from 1518 UK citizens to be nudged. Subsequently, we default all participants into donating to a charity of their choice, irrespective of self-reported consent. We find that the default nudge is equally effective for both consenting and non-consenting individuals, with negligible difference in average donations. However, non-consenting individuals report higher levels of resentment and regret and lower levels of happiness and support compared to the consenting group. Based on these findings, we argue that ignoring consent can have serious ethical ramifications for policy-making with nudges.

Synergistic effects of nudges and boosts in environmental education: Evidence from a field experiment

This study investigated the short-term and long-term impact of nudging and boosting within an environmental education program on students' environmental attitudes and energy-saving actions. We conducted a randomized assignment across primary and junior high schools, employing four study settings: board game-based environmental education without nudges or boosts (control); with nudges (setting energy-saving goals in a reflection session); with boosts (a game with a “tragedy of the commons” setting); and with both nudges and boosts. In the game with the “tragedy of the commons” setting, the specification was that pursuing self-interest would harm those of the entire group as well as one's own interests; the aim was to enhance environmental literacy by conveying the importance of cooperation through information. We found that students subjected to the boost became significantly more environmentally conscious in the game and set more goals in the goal-setting nudge task. A follow-up survey was conducted one- and three-months post-intervention. This revealed that students in the nudge-and-boost group, who set higher goals, displayed increased awareness of energy conservation, improved environmental attitudes, and greater adoption of energy-saving practices relative to the control group. The results suggest that combining nudges with boosts sustains the long-term effects of environmental education.

Are Dutch adults equally susceptible to nudging and pricing strategies? Secondary analyses of the Supreme Nudge parallel cluster-randomised controlled supermarket trial

BackgroundSupermarket interventions are promising to promote healthier dietary patterns, but not all individuals may be equally susceptible. We explored whether the effectiveness of nudging and pricing strategies on diet quality differs by psychological and grocery shopping characteristics.MethodsWe used data of the 12-month Supreme Nudge parallel cluster-randomised controlled supermarket trial, testing nudging and pricing strategies to promote healthier diets. Participants were Dutch speaking adults aged 30–80 years and regular shoppers of participating supermarkets (n = 12) in socially disadvantaged neighbourhoods. Data on psychological characteristics (food-related behaviours; price sensitivity; food decision styles; social cognitive factors; self-control) and grocery shopping characteristics (time spent in the supermarket; moment of the day; average supermarket visits; shopping at other retailers; supermarket proximity) were self-reported at baseline. These characteristics were tested for their moderating effects of the intervention on diet quality (scored 0–150) in linear mixed models.ResultsWe included 162 participants from intervention supermarkets and 199 from control supermarkets (73% female, 58 (± 10.8) years old, 42% highly educated). The interventions had no overall effect on diet quality. Only five out of 23 potential moderators were statistically significant. Yet, stratified analyses of these significant moderators showed no significant effects on diet quality for one of the subgroups and statistically non-significant negative effects for the other. Negative effects were suggested for individuals with lower baseline levels of meal planning (β − 2.6, 95% CI − 5.9; 0.8), healthy shopping convenience (β − 3.0, 95% CI − 7.2; 1.3), and healthy food attractiveness (β − 3.5, 95% CI − 8.3; 1.3), and with higher levels of price consciousness (β − 2.6, 95% CI − 6.2; 1.0) and weekly supermarket visits (β − 2.4, 95% CI − 6.8; 1.9).ConclusionsAdults with varying psychological and grocery shopping characteristics largely seem equally (un)susceptible to nudging and pricing strategies. It might be that certain characteristics lead to adverse effects, but this is not plausible, and the observed negative effects were small and statistically non-significant and may be explained by chance findings. Verification of these findings is needed in real-world trials based on larger sample sizes and with the use of more comprehensive interventions.Trial registrationDutch Trial Register ID NL7064, 30th of May, 2018, https://onderzoekmetmensen.nl/en/trial/20990

A Scoping Review of Nudges for Healthier Eating and their Applicability in Developing Asia

‘Nudges’ are considered a subtle tool to influence human behavior without restricting their choices. It is gaining attention in public policies and the healthcare domain to help people adopt positive changes for better healthcare outcomes. This paper undertakes a scoping review of literature to understand the effectiveness of nudges in choosing healthier food among people that have long-term implications towards lower incidence of medical conditions and healthier lifestyles. It digs deeper into techniques of nudges to identify the most effective ones and also identify the ones that could be used in developing Asian countries. The paper concludes that there is a greater proportion of studies that emphasize the positive relation between nudges and positive human behavior towards healthier eating, though these are mostly conducted in developed countries. The Visual nudge technique is the most used in the reviewed studies. For Asia, labeling and positioning nudges are appropriate nudges as they do not entail many additional costs to governments and institutions.

The effectiveness of a green default nudge in achieving resource conservation

Abstract Green nudges are used to promote conservation and pro-environmental behavior. This study examines the lasting effectiveness of a green default nudge in paper conservation, where price incentives are absent. At a private college in New York City, the default print setting was changed from single-sided to double-sided in Spring 2019, accompanied by a salient pop-up window that asked students to print double-sided. Analyzing student-level data over four semesters (Spring 2018 and Fall 2018 as control, Spring 2019 and Fall 2019 as treatment), this research contributes to the literature as it studies the effect of the nudge in the absence of pecuniary incentives. The findings support the hypothesis that this green default nudge was effective in promoting paper conservation and increasing resource efficiency. Results show that double-sided printing increased while single-sided printing decreased, leading to an overall reduction in paper usage. Employing a panel regression model with student fixed effects, this study finds that the nudge had a statistically significant effect in reducing the sheets per page ratio, and it improved the efficient use of paper by 19 percent. This inexpensive behavioral intervention proves successful in promoting environmental behavior and reducing paper consumption, which reduces greenhouse gas emissions.

Nudge-based misinformation interventions are effective in information environments with low misinformation prevalence

Nudge-based misinformation interventions are presented as cheap and effective ways to reduce the spread of misinformation online. However, despite online information environments typically containing relatively low volumes of misinformation, most studies testing the effectiveness of nudge interventions present equal proportions of true and false information. As the effectiveness of nudges can be highly context-dependent, it is imperative to validate the effectiveness of nudge-based interventions in environments with more realistic proportions of misinformation. The current study (N = 1387) assessed the effectiveness of a combined accuracy and social-norm nudge in simulated social-media environments with varying proportions of misinformation (50%, 20%, and 12.5%) relative to true and non-news-based (i.e., “social”) information. The nudge intervention was effective at improving sharing discernment in conditions with lower proportions of misinformation, providing ecologically valid support for the use of nudge-based interventions to counter misinformation propagation on social media.

Improving interest in public, active, and shared travel modes through nudging interventions

Nudging is a popular approach to changing behavior by designing interventions to encourage, for instance, sustainable or healthy actions without necessarily limiting freedom of choice. Nudging could show particular potential in changing travel behavior by providing governments with softer policy options to reduce the negative impacts of private vehicles in urban areas. This study examines the efficacy of nudging in changing interest in using public transport, active modes, and carsharing in Flanders, Belgium (n = 292), focusing on moral nudges, highlighting individual and social benefits, and norm nudges, using social pressure to promote appropriate behavior, through independent and paired sample t-tests, ANOVA mean-comparison tests, and multiple linear regression models. Results indicate that moral nudging is effective overall, but particularly for improving interest in carsharing, potentially providing an option for individuals wanting to make environmentally and socially conscious choices without drastically changing their lifestyles. Norm nudging was effective for public transport and especially active travel, indicating that mobility cultures and social acceptance are important to these modes. Attitudes toward public transport and carsharing were important to nudge susceptibility. Women might have greater concerns about making environmentally moral choices, resulting in higher moral nudge susceptibility, particularly for active travel, and trips taken with companions might be more easily swayed toward active modes. Those with greater time flexibility who are younger might be a target group for carsharing, especially when influenced by moral arguments, while older retired and full-time employed individuals may not be willing to give up their private cars and carsharing may not be practical for families with children. Nudging might be effective in changing travel behavior in conjunction with other policy measures to promote sustainable and healthy transport, ideally through a nudge unit to test, advise, and implement these subtle nudges. Further, the location, quality of transport services, and geographical density of cities are crucial aspects regarding the effectiveness of nudges in real-life scenarios.

Nudging News Readers: A Mixed-Methods Approach to Understanding When and How Interface Nudges Affect News Selection

Building on research on nudging as well as democratic news recommender design, this preregistered study employed a mixed-methods design to explore how interface nudges and article positioning affect news selection. Specifically, we tested whether a position nudge as well as three different types of interface nudges (e.g., popularity cues and social norm interventions) can facilitate readers’ engagement with current affairs news over other genres. To better understand how users processed and perceived the nudges, we further substantiated the experimental results with qualitative insights from a think-aloud protocol and semi-structured interviews. Our experimental results revealed strong effects of the position nudge, but no significant effects of interface nudges. Exploratory analyses indicated that interface nudges must be noticed to affect news selection, while our qualitative insights point to considerable individual-level differences in how nudges are perceived and evaluated. Thus, our study suggests that effective nudging requires carefully pre-tested design and a nuanced understanding of individual preferences.

Two randomized controlled trials of nudges to encourage referrals to centralized pharmacy services for evidence-based statin initiation in high-risk patients: Rationale and design of the SUPER LIPID program

In patients with or at risk for atherosclerotic vascular disease, statins reduce the incidence of major adverse cardiovascular events, but the majority of US adults with an indication for statin therapy are not prescribed statins at guideline-recommended intensity. Clinicians' limited time to address preventative care issues is cited as one factor contributing to gaps in statin prescribing. Centralized pharmacy services can fulfill a strategic role for population health management through outreach, education, and statin prescribing for patients at elevated ASCVD risk, but best practices for optimizing referrals of appropriate patients are unknown. SUPER LIPID (NCT05537064) is a program consisting of two pragmatic clinical trials testing the effect of nudges in increasing referrals of appropriate patients to a centralized pharmacy service for lipid management, conducted within 11 primary care practices in a large community health system. In both trials, patients were eligible for inclusion if they had an assigned primary care provider (PCP) in a participating practice and were not prescribed a high- or moderate-intensity statin despite an indication, identified via an electronic health record (EHR) algorithm. Trial #1 was a stepped wedge trial, conducted at a single practice with randomization at the PCP level, of an interruptive EHR message that appeared during eligible patients' visits and facilitated referral to the pharmacy service. For the first 3 months, no PCPs received the message; for the second 3 months, half were randomly selected to receive the message; and for the last 3 months, all PCPs received the message. Trial #2 was a cluster-randomized trial conducted at 10 practices, with randomization at the practice level. Practices were randomized to usual care or to have eligible patients automatically referred to centralized pharmacy services via a referral order placed in PCPs EHR inboxes for co-signature. In both trials, when a patient was referred to centralized pharmacy services, a pharmacist reviewed the patient's chart, contacted the patient, and initiated statin therapy if the patient agreed. The primary endpoint of both trials was the proportion of patients prescribed a statin; secondary endpoints include the proportion of patients prescribed a statin at guideline-recommended intensity, the proportion of patients filling a statin prescription, and serum low-density lipoprotein level. SUPER LIPID is a pair of pragmatic clinical trials assessing the effectiveness of two strategies to encourage referral of appropriate patients to a centralized pharmacy service for lipid management. The trial results will develop the evidence base for simple, scalable, EHR-based strategies to integrate clinical pharmacists into population health management and increase appropriate statin prescribing. clinicaltrials.gov; NCT05537064.