Implementation and Evaluation of Two Nudges in a Hospital’s Electronic Prescribing System to Optimise Cost-Effective Prescribing

Abstract

Providing healthcare workers with cost information about the medications they prescribe can influence their decisions. The current study aimed to analyse the impact of two nudges that presented cost information to prescribers through a hospital’s electronic prescribing system. The nudges were co-created by the research team: four behavioural scientists and the lead hospital pharmacist. The nudges were rolled out sequentially. The first nudge provided simple cost information (percentage cost-difference between two brands of mesalazine: Asacol® and Octasa®). The second nudge provided information about the potential annual cost savings if the cheaper medication were selected across the National Health Service. Neither nudge influenced prescribing. Prescribing of Asacol® and Octasa® at baseline and during the implementation of the first nudge did not differ (at p ≥ 0.05), nor was there a difference between the first nudge and second (at p ≥ 0.05). Although these nudges were not effective, notable administrative barriers were overcome, which may inform future research. For example, although for legal reasons the cost of medicine cannot be displayed, we were able to present aggregated cost information to the prescribers. Future research could reveal more behavioural factors that facilitate medication optimisation.

A behavioral intervention to promote use of multimodal pain medication for hospitalized patients: A randomized controlled trial

“…Other studies have found that having a preselected or “defaulted‐on” order has been shown to effect change 22 . Finally, alternative interventions to influence medication prescribing, such as showing cost information or cost savings, 23 have been equally unsuccessful at changing clinician behavior.…”

Electronic health record intervention to increase use of NSAIDs as analgesia for hospitalised patients: a cluster randomised controlled study

“…Most studies focusing on medications focus on medication deprescribing or medication reconciliation, as opposed to encouraging clinicians to add a medication 7 20–23. Finally, alternative interventions to influence medication prescribing, such as showing cost information or cost savings,8 have been unsuccessful at changing clinician behaviour. Laboratory test ordering is a straightforward outcome (ordered vs not), whereas medication ordering for analgesia then requires administration as well as better pain management and finally, opioid reduction.…”

“…Open access other interventions to improve patient care. [6][7][8][9] However, clinical decision support can add complexity and workflow tasks that contribute to clinician burn-out, and it needs to be justified in terms of clinical benefit. In a previous study, 10 we tested whether requiring an active choice for NSAID ordering (a 'hard stop') in the pain management order panel in our standard admission order set changed NSAID prescribing, but we found this approach to be ineffective.…”

“…Quality improvement projects can be both costly and time consuming to effectively implement. The electronic health record (EHR) provides a mechanism for reaching all clinicians in a health system and has been used to provide clinical decision support for medication use, recognising sepsis and many other interventions to improve patient care 6–9. However, clinical decision support can add complexity and workflow tasks that contribute to clinician burn-out, and it needs to be justified in terms of clinical benefit.…”