Polypharmacy
Conditions
Keywords
clinical decision support, electronic health record, behavioral economics, high-risk geriatric polypharmacy
Brief summary
High-risk polypharmacy is common among older adults in the United States, is particularly dangerous for individuals with dementia or cognitive impairment, and is associated with harms such as adverse drug reactions, falls, and higher costs of care. This project aims to test in a pragmatic clinic-randomized controlled trial two electronic health record-based behavioral economic nudges to help clinicians reduce high-risk polypharmacy among their older adult patients and in the subgroup with dementia or cognitive impairment. The main questions this trial aims to answer are: Aim 1: To evaluate the effects of an EHR-based commitment nudge, a justification nudge, and the combination of both nudges on a composite measure of high-risk polypharmacy via a pragmatic randomized controlled trial. The investigators will use cluster randomization in which primary care clinics are randomized to receive 0, 1, or 2 nudges using a factorial design. The nudges will run for 18 months, followed by 12 months of observation to assess persistence of effects. Aim 2: To qualitatively and quantitatively assess clinician experiences with the EHR-based nudges, including their acceptability and effects on workflow. At the conclusion of the intervention period, the investigators will perform semi-structured interviews and field a clinician survey.
Interventions
BEHAVIORALClinical decision support (CDS)-Commitment nudge
EHR clinical decision support alerts-clinician commitment to discuss high risk polypharmacy
OTHERClinician education
Brief, online education module for primary care clinicians
BEHAVIORALClinical decision support (CDS)-Justification nudge
EHR clinical decision support alerts-clinician rational for high risk polypharmacy
Sponsors
Northwestern University
National Institute on Aging (NIA)
University of Pittsburgh Medical Center
University of Southern California
University of California, Los Angeles
Study design
Allocation
RANDOMIZED
Intervention model
FACTORIAL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Northwestern Medicine or UPMC primary care clinic: Internal Medicine, Family Medicine, or General Practice or Geriatrics
Exclusion criteria
* None
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The percentage of HRPP with any (1 or more) of the 7 measures of high risk polypharmacy. (Composite measure) | 18 months | The composite of the 7 high-risk polypharmacy measures (Secondary outcomes #6-12) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| The rate of Emergency Department visits per patient -all cause | 18 months | Denominator: All older adults with HRPP. Numerator: Patients with an emergency department encounter during the look back period. |
| The rate of Emergency Department visits per patient-Adverse drug event (ADE)-specific | 18 months | Denominator: All older adults with HRPP. Numerator: Patients with an emergency department encounter for ADE during the look back period. |
| The rate of hospital admissions per patient-all cause | 18 months | Denominator: All older adults with HRPP. Numerator: Patients with an inpatient admission for any reason during the look back period. |
| The rate of hospital admissions per patient-ADE-specific | 18 months | Denominator: All older adults with HRPP. Numerator: Patients with an inpatient admission for ADE during the look back period. |
| The percentage of HRPP patients with a fall condition-drug interaction | 18 months | Denominator: All older adult patients with HRPP with a fall marker. Numerator: Patients with an active eligible fall risk medication on medication list. |
| The percentage of HRPP patients with a fall drug-drug interaction | 18 months | Denominator: All older adult patients with HRPP. Numerator: Patients with greater than or equal to 3 active eligible fall risk medications. |
| The percentage of HRPP patients with Heart failure-NSAID interaction | 18 months | Denominator: All older adult patients with HRPP with a CHF marker. Numerator: Patients with an active eligible NSAID medication. |
| The percentage of HRPP patients with Heart Failure-thiazolidinedione interaction | 18 months | Denominator: All older adults with HRPP with a CHF marker. Numerator: Patients with an active eligible thiazolidinedione medication. |
| The percentage of HRPP patients with Heart failure with reduced ejection fraction- non-dihydropyridine calcium channel blocker interaction | 18 months | Denominator: All older adults with HRPP with CHFlowEF marker. Numerator: Patients with an active eligible calcium channel blocker medication. |
| The percentage of HRPP patients with CKD-glyburide/glimepiride interaction | 18 months | Denominator: All older adults with HRPP with most-recent eGFR \<60. Numerator: Patients with an active eligible glyburide-containing medication. |
| The percentage of HRPP patients with CKD-NSAID interaction | 18 months | Denominator: All older adults with HRPP with most-recent eGFR \< 30. Numerator: Patients with an active eligible NSAID medication. |
Countries
United States
Outcome results
None listed