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

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.