An Electronic Health Record "Nudge" to Reduce Antipsychotic Medication Prescribing for Primary Care Patients With...

We hypothesized that an electronic health record (EHR) alert grounded in behavioral science could reduce new antipsychotic medication prescriptions for older adults with dementia.

We conducted a pragmatic clinical trial at a large academic health system, randomizing providers to receive the alert (intervention) or not (control) when prescribing new antipsychotic medications to outpatients with dementia. Eligible providers were those who previously signed a new antipsychotic prescription (n = 150). The EHR alert contained: (1) text stating that antipsychotic medications increase mortality risk; (2) a link to an after-visit summary handout describing non-pharmaceutical approaches; (3) a default to a lower dose and pill-days. The primary outcome was mean total pill-days over 19 months. We used provider-level linear regression, controlling for provider characteristics including prior prescribing behavior. Secondary outcomes included order cancellations and exploratory analyses of treatment effects among providers with above-average baseline prescribing patterns.

Between 9/15/2021 and 4/11/2023, 28 providers in the intervention and 21 in the control arm initiated prescriptions to eligible patients, resulting in 139 enrolled patients; mean patient age was 83 (SD 9.7); 67% female. After 19 months, raw mean (SD) pill-days were 126 (228) for the intervention and 225 (601) for the control group. Intervention assignment was not significantly associated with total pill-days among enrolled patients (primary outcome, mean difference -113 [95% CI: -256, +30], p = 0.12). Orders were canceled in 12/58 (21%) of intervention encounters. The intervention was estimated to reduce pill-days for providers with average baseline prescribing behavior (-126, 95% CI: -3, -248; p = 0.04); for each additional 10 baseline pill-days, this reduction effect increased by -8.8 pill-days (95% CI: -3.9, -13.6; p < 0.001).

This EHR alert did not reduce the primary outcome of antipsychotic pill-days. However, the nonsignificant effect size was substantial, and exploratory analyses revealed that the intervention significantly reduced pill-days for providers with average baseline prescribing. Future alerts should test targeting high prescribers.