Generic Medication Prescription Rates After Health System–Wide Redesign of Default Options Within the Electronic Health Record

Patel, Mitesh S.; Day, Susan; Halpern, Scott D.; Hanson, C. William; Martinez, Joseph; Honeywell, Steven; Volpp, Kevin G.

doi:10.1001/jamainternmed.2016.1691

Cited by 111 publications

(89 citation statements)

References 6 publications

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“…Our study adds to the literature by focusing on clinician‐level performance data as a means for targeted QI as well as highlighting the dynamic nature of low‐value care. For example, because most potentially low‐value prescriptions began appropriately but then continue without an indication, an EHR choice architecture automatically defaulting prescriptions to the lowest dose, 8 weeks' duration, and no refills could reduce needless long‐term PPIs with minimal clinical workflow disruption . However, these defaults may inadvertently stop necessary PPIs if they lack clinical nuance .…”

Section: Discussionmentioning

confidence: 99%

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Mafi

May

Kahn

et al. 2019

J American Geriatrics Society

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BACKGROUND Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low‐value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced‐based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline‐based (1) short‐term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long‐term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger‐Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low‐value PPI prescription prevalence. RESULTS Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%‐40.7%) were potentially low value—of which 82% began appropriately (eg, GERD) but then continued long term without a guideline‐based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low‐value prescriptions. CONCLUSION One in eight older adults were prescribed a PPI, and over one‐third of prescriptions were potentially low‐value. Most often, appropriate short‐term prescriptions became potentially low value because they lacked long‐term indications. With most potentially low‐value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR‐based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600–2604, 2019

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Section: Discussionmentioning

confidence: 99%

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Mafi

May

Kahn

et al. 2019

J American Geriatrics Society

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“…In one recent study, an electronic health record intervention was introduced in which generic medication was the default when physicians were entering prescriptions. With this default in place, rates of generic prescribing immediately increased significantly and dramatically for all tested categories of medicine except one . The exception was for levothyroxine (trade name: Synthroid), one of the few medications about which physicians are commonly taught that metabolism of the generic and trade brand may be different and for which intentional prescription of the trade brand is common.…”

Section: Nudges and Preferencesmentioning

confidence: 99%

Justifying Clinical Nudges

Gorin¹,

Joffe²,

Dickert³

et al. 2017

Hastings Center Report

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The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as "nudges." Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations-for example, the tendency to choose the first option presented even when that option is not the best for them-thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients' choices, the justification for doing so must appeal to an ethical and professional standard, not to patients' preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar-the best-interest standard-offers a robust justification for the use of nudges.

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“…When we implemented this change in our EHR, generic prescribing rates increased from 75% to 98%. 2 Clinical settings also play an important role. We found that reducing the default duration of opioid prescriptions may make sense for acute conditions often seen in the emergency department but may be inappropriate for clinicians caring for patients with chronic pain.…”

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confidence: 99%