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Behavioral Economics Applications to Geriatrics Leveraging EHRs (BEAGLE R21)

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ClinicalTrials.gov Identifier: NCT03704389
Recruitment Status : Active, not recruiting
First Posted : October 12, 2018
Last Update Posted : July 31, 2019
Sponsor:
Collaborators:
University of California, Los Angeles
University of Southern California
Information provided by (Responsible Party):
Stephen Persell, MD, MPH, Northwestern University

Brief Summary:

The risks and benefits of many diagnostic approaches and treatments differ for older adults compared to middle aged adults. When diagnostic and therapeutic strategies are misapplied to older adults this can lead to increased morbidity and mortality. Well established examples where clinicians do not often follow best practices in the care of older adults include those identified by the American Geriatrics Society for the Choosing Wisely initiative: 1) testing and treatment for asymptomatic bacteriuria, 2) prostate specific antigen testing in older men without prostate cancer, and 3) overuse of insulin or oral hypoglycemics for type 2 diabetes.

Clinical decision support nudges, informed by social psychology and delivered via electronic health records (EHRs), are promising strategies to reduce the misuse of services in cases where optimal utilization may not be zero but should be well below current practice. These interventions seek to influence conscious and unconscious drivers of clinical decision making, are low cost to implement and disseminate, and can be incorporated into existing delivery systems. In the R21 phase of this Behavioral Economics Applications to Geriatrics Leveraging EHRs (BEAGLE) study, we will: select EHR delivered nudges to address 3 topics of potential misuse in older adults based on the main psychological drivers of overuse identified in interviews with high-using clinicians; develop and pilot test decision support tools within a health systems' EHR to understand technical feasibility, work flow fit, preliminary impact on clinical outcomes, and clinician acceptability; and develop and validate electronic clinical quality measures of potential overuse/misuse related to the care of older adults.


Condition or disease Intervention/treatment Phase
Prostate Specific Antigen Asymptomatic Bacteriuria Type 2 Diabetes Mellitus Behavioral: Clinical decision support Not Applicable

Detailed Description:
The risks and benefits of many diagnostic approaches and treatments differ for older adults compared to middle aged adults. When diagnostic and therapeutic strategies are misapplied to older adults this can lead to increased morbidity and mortality. Well-established examples where clinicians do not often follow best practices in the care of older adults include those identified by the American Geriatrics Society for the Choosing Wisely initiative: 1) testing and treatment for asymptomatic bacteriuria, 2) prostate specific antigen testing in older men without prostate cancer, and 3) overuse of insulin or oral hypoglycemics for type 2 diabetes. There are several hypotheses as to why clinicians fail to incorporate best evidence into geriatric clinical care. First, they may underestimate downstream harms of testing which seems easy to do (e.g., a urinalysis for a non-specific symptom) or treatment that may be appropriate for younger patients (e.g. intensifying insulin to achieve tight control). Second, clinicians may overweigh the risks of not performing the action (e.g., missing cancer diagnosis, failing to diagnose UTI in a patient presenting without urinary tract symptoms). Third, clinicians may respond to real or perceived social norms (from patients and their families, other clinicians or both) that set expectations to behave in specific ways. Fourth, force of habit may lead clinicians to act in a way similar to how they have done in the past even if current evidence doesn't support it. And fifth, clinicians may overuse a test or treatment to avoid feeling they are expressing an ageist bias toward their patients. Clinical decision support nudges, informed by social psychology and delivered via electronic health records (EHRs), are promising strategies to reduce the misuse of services in cases where optimal utilization may not be zero but should be well below current practice. These interventions seek to influence conscious and unconscious drivers of clinical decision making, are low cost to implement and disseminate, and can be incorporated into existing delivery systems. In the R21 phase of this Behavioral Economics Applications to Geriatrics Leveraging EHRs (BEAGLE) study, we will: select EHR delivered nudges to address 3 topics of potential misuse in older adults based on the main psychological drivers of overuse identified in interviews with high-using clinicians; develop and pilot test decision support tools within a health systems' EHR to understand technical feasibility, work flow fit, preliminary impact on clinical outcomes, and clinician acceptability; and develop and validate electronic clinical quality measures of potential overuse/misuse related to the care of older adults.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 14 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Health Services Research
Official Title: Behavioral Economics Applications to Geriatrics Leveraging EHRs
Actual Study Start Date : January 17, 2019
Actual Primary Completion Date : July 17, 2019
Estimated Study Completion Date : August 18, 2019

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Experimental: Clinical decision support intervention
Participating clinicians will receive any of three clinical decision support nudges within the electronic health record when all eligibility criteria are met within a patient's chart.
Behavioral: Clinical decision support
Clinical decision support nudges within the electronic health record




Primary Outcome Measures :
  1. Misuse of urinalysis or urine culture in older women [ Time Frame: 6 months ]
    Proportion of women aged 65 years and older who underwent a urinalysis and/or urine culture for suspected UTI who did not have genitourinary specific symptoms

  2. PSA testing in the elderly [ Time Frame: 6 months ]
    Proportion of men 76 and older with no history of prostate cancer who had a PSA test done during the measurement period

  3. Diabetes overtreatment in the elderly [ Time Frame: 6 months ]
    Proportion of diabetes patients 75 and older treated with insulin or oral hypoglycemic with hemoglobin A1c less than 7.0.



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Northwestern Medicine primary care iclinician caring for adults
  • Provides informed consent

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03704389


Locations
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United States, Illinois
Northwestern Medicine
Chicago, Illinois, United States, 60611
Sponsors and Collaborators
Northwestern University
University of California, Los Angeles
University of Southern California

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Responsible Party: Stephen Persell, MD, MPH, Associate Professor; Director, Center for Primary Care Innovation, Northwestern University
ClinicalTrials.gov Identifier: NCT03704389     History of Changes
Other Study ID Numbers: STU00205722
First Posted: October 12, 2018    Key Record Dates
Last Update Posted: July 31, 2019
Last Verified: July 2019
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by Stephen Persell, MD, MPH, Northwestern University:
Geriatrics
Clinical decision support
Behavioral Economics
Additional relevant MeSH terms:
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Bacteriuria
Urinary Tract Infections
Infection
Urologic Diseases