268262 Using nudges to influence prescription behavior: A novel behavioral economics approach to heart disease prevention

Monday, October 29, 2012

Brian Elbel, PhD, MPH , NYU School of Medicine and NYC Wagner School of Public Service, New York University, New York, NY
Joseph Ravenell, MD, MS , Department of Population Health, New York University School of Medicine, New York, NY
James Underberg, MD, MS , Internal Medicine and Lipidology, Murray Hill Medical Group, New York, NY
Kevin C. Lo, MPH , Medicine, New York Unversity School of Medicine, New York, NY
Olivia Martinez , Medicine, New York University School of Medicine, New York, NY
Edward Barnes, MD , Murray Hill Medical Group, New York, NY
Background Despite consensus guidelines for lowering lipids to prevent coronary heart disease (CHD), gaps persist between actual and optimal guideline adherence among physicians. Implementing guideline-based protocols through Electronic Health Record (EHR) systems, and a behavioral economics approach where the “default option” is altered, are novel strategies that may influence provider guideline adherence in a sustainable way.

Objective To examine the comparative effectiveness of an opt-out, guideline-based EHR-driven protocol (“Nudge”) versus usual care for cholesterol management in a multispecialty private practice .

Methods In a cluster-randomized trial, 20 internists caring for 400 statin-eligible patients will be randomly assigned to: 1) usual care; or 2) an intervention in which the EHR is programmed to automatically initiate a statin titrating/monitoring protocol for all patients meeting ATP III criteria for statin-therapy, unless the physician actively chooses a different treatment course. Choice is not restricted, but the guideline-concordant choice becomes the simplest choice. The primary outcome is the percentage of statin-eligible patients on ATP III-concordant therapy at 6 months.

Results Preliminary electronic review identified 2734 statin-eligible patients seen in the last year, with 1627 (60%) not on statins. 313 statin-eligible patients were diagnosed with CHD, of whom 30% were not on statins. Patient/physician recruitment is underway.

Implications Our behavioral economics-based, EHR system-level intervention represents a powerful tool by which to influence provider behavior with minimal disruption to clinical workflow. If successful, the public health impact can be significant; the potential for dissemination and scalability are high, given the ubiquity of EHR systems in clinical practices.

Learning Areas:
Chronic disease management and prevention
Communication and informatics
Conduct evaluation related to programs, research, and other areas of practice
Public health administration or related administration
Public health or related organizational policy, standards, or other guidelines
Social and behavioral sciences

Learning Objectives:
1. Identify the relevance of behavioral economics in optimizing the use of health information technology and systems. 2. Evaluate the effectiveness of a default option (Nudge) in EHR to influence the providers to use the “better” choice. 3. Discuss the use of behavioral economics tools to increase adherence to guidelines for preventing the onset of CHD.

Keywords: Cholesterol, Information Technology

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: My background is in health economics and health policy, and I have used behavioral economics in prior, successful foundation and federally funded projects. I study how individuals make decisions that influence their health and health care, with a particular emphasis on obesity and related problems, and the role and influence of public policy. All of my work uses behavioral economics to address complex health-related decision-making.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.