Systematic review of clinician-directed nudges in healthcare contexts

Last, Briana S.; Buttenheim, Alison M.; Timon, Carter E.; Mitra, Nandita; Beidas, Rinad S.

doi:10.1136/bmjopen-2021-048801

Cited by 87 publications

(80 citation statements)

References 90 publications

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“…Despite the lower-than-anticipated rates of opioid prescribing and clinician exposure to multiple opioid prescribing interventions, we still observed statistically significant decreased odds of prescribing in the comparison groups, even before the initial comparison emails were sent. These results add to the growing literature that low-effect nudges can result in opioid prescribing changes and other health benefits, 24 , 25 , 30 , 31 , 32 , 33 even in the context of likely concurrent interventions.…”

Section: Discussionsupporting

confidence: 54%

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain

et al. 2022

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Section: Discussionsupporting

confidence: 54%

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain

et al. 2022

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“…Though the innovation tournament fielded ideas from stakeholders across PIC practices, it is important to test whether the tablet strategy will generalize to other primary care practices where depression screening and stakeholder investment may be lower. It is possible that at other practices where there is less buy-in or motivation, social incentives and peer comparison interventions would be needed to complement these efforts [ 78 , 79 ]. Going forward, leveraging the leadership and embeddedness of implementation champions will be crucial to effecting large-scale change in the entire health system [ 80 ].…”

Section: Discussionmentioning

confidence: 99%

A pilot study of participatory and rapid implementation approaches to increase depression screening in primary care

et al. 2021

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Background Most individuals with depression go unidentified and untreated. In 2016 the US Preventive Services Task Force released guidelines recommending universal screening in primary care to identify patients with depression and to link them to treatment. Feasible, acceptable, and effective strategies to implement these guidelines are needed. Methods This three-phased study employed rapid participatory methods to design and test strategies to increase depression screening at Penn Medicine, a large health system with 90 primary care practices. First, researchers solicited ideas and barriers from stakeholders to increase screening using an innovation tournament—a crowdsourcing method that invites stakeholders to submit ideas to address a workplace challenge. Second, a panel of stakeholders and scientists deliberated over and ranked the tournament ideas. An instant runoff election was held to select the winning idea. Third, the research team piloted the winning idea in a primary care practice using rapid prototyping, an approach that quickly refines and iterates strategy designs. Results The innovation tournament yielded 31 ideas and 32 barriers from diverse stakeholders (12 primary care physicians, 10 medical assistants, 4 nurse practitioners, 2 practice managers, and 4 patient support assistants). A panel of 6 stakeholders and scientists deliberated on the ideas and voted for patient self-report (i.e., through tablet computers, text message, or an online patient portal) as the winning idea. The research team rapid prototyped tablets in one primary care practice with one physician over 5 five-hour shifts to examine the feasibility, acceptability, and effectiveness of the strategy. Most patients, the physician, and medical assistants found the tablets acceptable and feasible. However, patient support assistants struggled to incorporate them in their workflow and expressed concerns about scaling up the process. Depression screening rates were higher using tablets compared to usual care; follow-up was comparable between tablets and usual care. Conclusions Rapid participatory methods engaged and amplified the voices of diverse stakeholders in primary care. These methods helped design an acceptable and feasible implementation strategy that showed promise for increasing depression screening in a primary care setting. The next step is to evaluate the strategy in a randomized controlled trial across primary care practices.

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“…Interventions informed by behavioral science embedded within the electronic health record (EHR) have been utilized in quality improvement efforts within primary care, and some have been effective. 1 2 Accountable justification alerts are one such behavioral intervention that led to a reduction in inappropriate antibiotic prescribing for acute respiratory infections. 3 4 5 Accountable justification alerts prompt a clinician who is ordering a potentially guideline-discordant test or treatment to enter a free-text rationale for why their clinical decision should override the presented clinical guideline or recommendation.…”

Section: Background and Significancementioning

confidence: 99%

A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions

et al. 2022

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Background Requiring accountable justifications—visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert—has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts. Methods We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications. Results There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for “anxiety” or “acute pain”); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., “risks and benefits discussed”). Most accountable justifications (65%) were of uncertain clinical appropriateness. Conclusion Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making.

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Systematic review of clinician-directed nudges in healthcare contexts

Cited by 87 publications

References 90 publications

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain

A pilot study of participatory and rapid implementation approaches to increase depression screening in primary care

A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions

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