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Development of High-Risk Geriatric Polypharmacy Electronic Clinical Quality Measures and a Pilot Test of EHR Nudges
Stephen D Persell1,2, Tiffany Brown3, Jason N Doctor4,5
1Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Dr., 10th floor, Chicago, IL, 60611, USA. spersell@nm.org.
Background:
Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms.
Objective:
To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing.
Design:
We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019.
Participants:
Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot.
Main Measures:
Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease.
Interventions:
Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a "commitment nudge" that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a "justification nudge" that asked for a reason when high-risk polypharmacy was present. One practice received both.
Key Results:
Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%).
Conclusions:
EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.
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