Professional role and hierarchy shape adherence to electronic alerts for laboratory test ordering

Healthcare systems face increasing pressure to reduce costs and improve care quality. Guideline adherence is essential for optimal patient outcomes, yet compliance remains inconsistent. Nudges - behavioral interventions modifying decision environments - have shown potential to enhance adherence, but their effectiveness varies by professional role and organizational factors. This study examines the impact of nudges on laboratory test prescriptions, assessing their effectiveness based on prescriber demographics, professional role, and hierarchical position. Additionally, it explores alert fatigue and prescriber perceptions of these interventions. A dataset of 929,808 laboratory test prescriptions issued between July 2021 and March 2024 across the Swiss EOC hospitals was analyzed. Prescription details, prescriber demographics, and alert outcomes were examined. Monthly adherence rates to alerts and appropriate prescription rates were assessed overall and by professional role. A cross-sectional survey (12-item Likert scale) evaluated prescriber perceptions. Statistical analyses included descriptive statistics, chi-square tests, time series analysis, and exploratory factor analysis (EFA) with varimax rotation. Group differences were analyzed using the Kruskal-Wallis test, Dunn's procedure, and the Mann-Whitney U test. Of all prescriptions, 12.4% triggered alerts due to non-compliance with guideline-based Minimal Retesting Interval (MRI) criteria, internal standards collaboratively developed by EOC laboratory specialists and clinicians, aligned with international recommendations on laboratory test appropriateness. Among these, 11.9% of orders were canceled following the alert. Of these, 11.9% were canceled. Alert adherence varied by role, highest among heads of service (19.9%) and lowest among residents (9.6%). Compliance increased with age (p < 0.0001) and experience (p < 0.001) but declined over time (β = -0.08, p = 0.003), suggesting alert fatigue. Perceived usefulness of alerts was higher among nurses than physicians (p < 0.001). Despite greater adherence, senior physicians found alerts less useful. Professional hierarchy influences alert adherence, and sustaining behavioral change remains challenging. While electronic alerts can improve guideline compliance, alert fatigue limits long-term effectiveness. Optimizing alert design through personalization and context-aware triggers may enhance engagement. These findings provide insights for improving nudge-based interventions in clinical practice.