Behavioral Economics Applications to Geriatrics Leveraging EHRs (BEAGLE R21)

• ClinicalTrials.gov Identifier: NCT03704389
• Recruitment Status: Completed
• First Posted: October 12, 2018
• Last Update Posted: September 9, 2020
• Sponsor: Northwestern University
• Collaborators: University of California, Los Angeles; University of Southern California
• Information provided by (Responsible Party): Stephen Persell, MD, MPH, Northwestern University

Study Description

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.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 14 participants
• Allocation: N/A
• 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
• Actual Study Completion Date: August 18, 2019

Arms and Interventions

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

Outcome Measures

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.

Eligibility Criteria

• 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 clinician caring for adults
• Provides informed consent

Contacts and Locations

Locations

United States, Illinois

Northwestern Medicine

Chicago, Illinois, United States, 60611

Sponsors and Collaborators

Northwestern University

University of California, Los Angeles

University of Southern California

More Information

• Responsible Party: Stephen Persell, MD, MPH, Associate Professor; Director, Center for Primary Care Innovation, Northwestern University
• ClinicalTrials.gov Identifier: NCT03704389
• Other Study ID Numbers: STU00205722
• First Posted: October 12, 2018
• Last Update Posted: September 9, 2020
• Last Verified: September 2020

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

• 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:

Bacteriuria; Diabetes Mellitus, Type 2; Diabetes Mellitus; Glucose Metabolism Disorders; Metabolic Diseases; Endocrine System Diseases; Urinary Tract Infections; Infections; Urologic Diseases