21259 BB - LEONARD DAVIS INSTITUTE of HEALTH ECONOMICS ResearchBRricF Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing A Cluster Randomized Clinical Trial Srinath Adusumalli, Genevieve P. Kanter, Dylan S. Small, David A. Asch, Kevin G. Volpp, Sae-Hwan Park, Yevgeniy Gitelman, David Do, Damien Leri, Corinne Rhodes, Christine VanZandbergen, John T. Howell, Mika Epps, Ann M. Cavella, Michael Wenger, Tory O. Harrington, Kayla Clark, Julie E. Westover, Christopher K. Snider, and Mitesh S. Patel JAMA Cardiology - Published November 2022 Key Findings Nudges - which present information or set choices to achieve desired behavior - increased guideline- based statin prescribing over usual care. Clinician nudges alone had a small effect, patient nudges alone had no effect, and combined clinician and patient nudges had the greatest effect, increasing prescribing by 7.2 percentage points. The interventions employed a common electronic health record (EHR ) system, making them generalizable and scalable. THE RESEARCH QUESTION clinicians, and at the combination of the two, and the researchers examined which approach worked best to Cardiovascular disease is the leading cause of death in the . i 0 increase statin prescribing. U.S. Statins, cholesterol-lowering drugs, are recommended for most people with cardiovascular disease, as they significantly reduce risk of cardiovascular events and related THE FINDINGS morbidity and mortality. Despite this, many people eligible When the nudges were aimed at clinicians, statin for statins based on current guidelines do not receive them prescribing increased by 5.5 percentage points compared to from their clinician. usual care. Nudges were also effective at increasing statin Nudges are a promising approach to increase the use of use when they targeted a combination of clinicians and medications such as statins. Typically, nudges are small patients. In that case, statin prescribing increased by 7.2 changes in the way information is framed or in the choices percentage points. When the nudges were aimed at patients offered to patients and clinicians. Despite the small alone, statin prescribing did not significantly change. changes, nudges can have a surprisingly large impact on During a 12-month preintervention period, in unadjusted behavior, including medication prescribing. analyses, the rate of new statin prescribing at visits was In this study, the authors conducted a randomized under 5% in some study arms. With both clinician and controlled trial to test the effect of nudges on statin patient nudges, new statin prescribing rose to as high as prescribing. The nudges were aimed at patients, at 16% for eligible patients not already taking a statin. The trial had no serious adverse events. Leonard Davis Institute of Health Economics | 1 ResearchBrier THE IMPLICATIONS Combining patient and clinician nudges synergistically changed prescribing behavior to increase guideline-directed care. The clinician nudges were automated in a widely used EHR, so they are scalable, pragmatic, and a template for making nudges a standard feature of health care. EHR- based nudges can be add-ons to a delivery system's EHR or could become a foundational technology of health IT systems, after rigorous evaluation and in collaboration with EHR vendors. Digital companies such as Netflix, Amazon, and Facebook effectively nudge users into desired behavior. Automated EHR-based nudges use the same digital strategies to make guideline-based care easy, by presenting the right information to the right person at the right point in the workflow. Lessons for Future Interventions This study's nudge intervention is a model for effective health IT implementation design, involving collaboration between the research team, primary care practices, and health system IT team. The clinician nudge was cocreated with clinicians in an iterative process to ensure uptake and an intuitive user experience. The results indicate that nudging clinicians in conjunction with patients may be most effective in altering behavior. Further more, clinician peer comparison feedback establishes norms and benchmarks for desired behavior, and EHR prompts provide a way to act according to the norms established by peer comparisons. Additional work in progress includes a qualitative report on patient perceptions of the statin text message nudges. THE STUDY The authors determined the effect of nudges on statin prescribing by randomizing 28 primary care practices to one of four options: usual care; clinician nudge; patient nudge; or clinician and patient nudges. The primary care practices were part of the University of Pennsylvania Health System, where about 70% of eligible patients had statin prescriptions. The study focused on the remaining patients. Clinician nudges were implemented in an EHR prompt to order or not order statins for eligible patients during ABOUT PENN LDI Figure 1. Statin Prescribing Relative to Usual Care 8% 7% Vo 6% 5% 5.5% 4% 3% 2% 1% 0% Patient Nudge PERCENTAGE POINT INCREASE Clinician Nudge Clinician Nudge + Patient Nudge patient visits, plus a monthly feedback report showing statin prescribing of the clinician compared to their peers. Patient nudges were text messages sent a few days before a primary care visit about the risks and benefits of statins with a suggestion to discuss them at their upcoming visit. Researchers monitored statin prescribing in the randomized practices over the preintervention and six-month intervention period from October 2019 to April 2021. Practices in the study saw a patient group that included 4131 individuals. Among those, 66% were white and 29% were Black, the average age was 66 years, and 23% had atherosclerotic cardiovascular disease. The primary outcome was initiation of a statin prescription during the visit. Adusumalli, S., Kanter, G.P, Small, D.S., Asch, D.A., Volpp, K.G., Park, S-H, Gitelman, Y., Do, D., Leri, D., Rhodes, C., VanZandbergen, C., Howell, JT,, Epps, M., Cavella, AM., Wenger, M., Harrington, T.O., Clark, K., Westover, JE., Snider, CK, Patel, M.S. (2022). Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial. JAMA Cardiology. Published online November 30, 2022. doi:10.1001/jamacardio.2022.4373. The study was supported by a grant from by the National Institute on Aging (R33AG057380) and the University of Pennsylvania Health System through the Penn Medicine Nudge Unit. Since 1967, the University of Pennsylvania's Leonard Davis Institute of Health Economics (Penn LDI) has been the leading university institute dedicated to data-driven, policy-focused research that improves our nation's health and health care. Penn LDl's priority areas include (1) health care access and coverage; (2) health equity; (3) improving care for older adults; (4) opioid epidemic; and (5) population health. Penn LDI connects all twelve of Penn's schools, the University of Pennsylvania Health System, and the Children's Hospital of Philadelphia through its more than 400 Senior Fellows. Learn more at Idi.upenn.edu | @ @PennLDI & Penn LEONARD DAVIS INSTITUTE of HEALTH ECONOMICS Leonard Davis Institute of Health Economics | 2