Timely EHR Nudges Linked to Increased Statin Prescription in Primary Care Settings

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A cluster randomized trial from Penn Medicine's Nudge Unit provides insight into the effects of "nudges" in primary care settings for improving the prescription of statins.

The latest data release from Penn Medicine’s Nudge Unit is suggests nudges to primary care clinicians was associated with increased initiation of a statin prescription during primary care visits.

A cluster randomized trial assessing use of electronic prompts for clinicians and patients suggests EHR nudges delivered to clinicians were effective for increasing statin prescription rates in primary care settings with or without a patient nudge, while patient nudges, which were delivered via text message, were found to be ineffective when used alone.

“To our knowledge, this study is one of the largest clinical trials testing nudges to clinicians and patients. Because these interventions were automated through the EHR, they provide a scalable template that can be used by health systems more broadly to improve patient care,” wrote investigators.

As technology has advanced, optimizing use of these new technologies in care has become a focus for millions within the healthcare community. This extensive research commitment has culminated in the creation of groups like the Nudge Unit at Penn Medicine. Billed as the world’s first behavioral design team embedded within a health system, the Nudge Unit hopes to leverage insights auto des, implement, and assess scalable electronic prompt programs aimed at improving patient outcomes.

Led by Srinath Adusumalli, MD, MSHP, MBMI, the deputy director at the Penn Medicine Nudge Unit, the current trial was designed as a cluster randomized clinical trial and included 4131 patients from 28 primary care practices urban and suburban Pennsylvania and New Jersey. The 4131 patients were randomized in a 1:1:1:1 ratio to a usual care group,a patient nudge group, a clinician nudge arm, and a combined nudge group.

The trial itself included a 12-month preintervention period and a 6-month intervention period. The preintervention period was used to identify clinicians who treated fewer than 10 patients eligible for a new statin prescription during the 12 months preceding the trial.

Statins were prescribed to 5.6% of patients in the usual care group, 4.8% in the patient nudge group, 6.0% in the clinician nudge group, and 4.7% in the combined group during the preintervention period. Investigators pointed out the overall study cohort had a mean age of 65.5 (SD, 10.5) years, 51.3% were male, 29.3% were Black, 2.6% were Hispanic, and 66.1% were White. At baseline, 22.6% (n=933) had atherosclerotic cardiovascular disease.

Results of the investigators’ analysis suggested statins were prescribed to 7.3% of patients in the usual care group, 8.5% in the patient nudge group, 13.0% in the clinician nudge arm, and 15.5% in the combined group during the intervention period of the trial. In adjusted analyses comparing nudges against usual care, results indicated clinician nudges were associated with significantly increased statin prescribing alone (5.5 percentage points [95% CI, 3.4 to 7.8]; P = .01) and when combined with the patient nudge (7.2 percentage points [95% CI, 5.1 to 9.1]; P=.001). In contrast, patient nudges alone did not significantly increase statin prescribing relative to usual care (0.9 percentage points [95% CI, −0.8 to 2.5]; P = .32).

In an invited commentary, Faraz S. Ahmad, MD, MS, and Stephen D. Persell, MD, both of Northwestern University, commended investigators for their trial and the insights provided but also cautioned against overinterpretation of results, specifically the effectiveness of clinician-directed nudges versus patient-directed nudges.

“We commend the authors for this rigorous, pragmatic study testing clinician and patient nudges embedded into routine care of patients in primary care clinics and conducted under a waiver of consent for clinicians and patients. The capability to rapidly conduct pragmatic trials like this comprises an essential component of learning health systems for cardiovascular care,” wrote the pair.

This study, “Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing,” was published in JAMA Cardiology.