Speaker
Julie Lauffenburger, PharmD, PhD
Associate Professor of Medicine
Brigham and Women’s Hospital and Harvard Medical School
Keywords
Adaptive trial design; Behavioral science; Deprescribing; electronic health record; EHR; Inappropriate prescribing; NUDGE-EHR; Overprescribing.
Key Points
- Older adults are often overprescribed medications or prescribed potentially inappropriate medications like benzodiazepines, non-benzodiazepine sedative hypnotics, or strongly anticholinergic medications with long-term use associated with a 30% increased risk of hospitalizations and falls.
- Medication management or optimization in older adults is often difficult due to a tendency to maintain the status quo, time constraints, patient preference, or diffusion of responsibility, and existing interventions for medication management are highly resource intensive.
- Behavioral science techniques employed in the NUDGE-EHR and NUDGE-HER-2 trials may enhance the effectiveness of electronic health record (EHR) tools to alert clinicians to inappropriate medications during patient visits.
- NUDGE-EHR was a 16 arm two-stage adaptive pragmatic trial among 216 primary care providers and older adult patients conducted from October 2020 to August 2022 examining 14 promising EHR tools using 9 different behavioral principles with deprescribing as a primary outcome.
- The 2 most promising tools were included in the second 3 parallel arm pragmatic trial, NUDGE-EHR-2, in a different health system from November 2022 to March 2024. EHR tools used pop-up windows to suggest deprescribing. The study provided a set of helpful options to providers including a tapering algorithm, instructions for patients, orders for alternative medications, and referrals to behavioral health providers to make this process faster and easier.
- Deprescribing increased by 6.5% to 10.4% over usual care. Active discontinuation by primary care providers appeared to drive the results.
Discussion Themes
The adaptive trial design of the first NUDGE-EHR study helped inform the more traditional confirmation trial NUDGE-EHR-2.
The way EHR tools are used varies widely from provider to provider. Tools may be adapted over time so the tool works best for the individual provider.
Read more about the NUDGE-EHR study.