Document text
Principal Investigator: Safiya Richardson
Organization: NEW YORK UNIVERSITY SCHOOL OF MEDICINE
Fiscal Year: 2024
Award: $785,951
Funding agency: National Heart Lung and Blood Institute
PROJECT ABSTRACT Every year 2.4 million CT scans are performed to evaluate for pulmonary embolism
(PE) in Emergency Departments (ED) in the United States. Approximately one-third of studies are avoidable,
with each scan resulting in unnecessary exposure to radiation and increasing risk for iatrogenic lung cancer
and heart disease. The use of clinical prediction rules to assess pre-test probability before CT reduces testing
by 25% without any missed PEs. Several professional society guidelines recommend their use. However,
providers do not use these tools, or use them incorrectly, in up to 80% of patients. Clinical decision support
(CDS) that incorporates well-validated clinical prediction rules can improve the use of evidence-based
diagnostic testing strategies however impact is often limited by low provider adoption. Integrating insights from
behavioral economics, including nudges, into CDS design is a novel approach to improving adoption of CDS
and evidence-based practices that minimizes negative impacts on clinical workflow and cognitive load. Nudges
are defined as positive reinforcement and indirect suggestions which have a non-forced effect on decision
making. For example, ‘opt-out’ options for organ donation consent led to striking differences in enrollment. The
central hypothesis of this proposal is that a CDS tool incorporating a theory-informed “nudge” will address
identified behavioral barriers to use and improve provider adoption of guideline-concordant CT ordering for PE.
Our team developed, pilot tested, and demonstrated preliminary efficacy of a CDS tool + Nudge. The tool
supported PE risk stratification by leveraging a well-validated clinical prediction rule and included a nudge
designed to address identified barriers to adoption. Adoption rates for the CDS tool + Nudge were almost
double the adoption rates for the CDS tool alone. We propose to conduct a large, multisite, hybrid type III trial
to evaluate CDS tool + Nudge. The CDS tool’s innovative technological architecture enables its seamless
implementation across sites. The tool was developed on an electronic health record (EHR)-agnostic web-
based platform, designed for dissemination to work with any EHR using the open communication protocol Fast
Healthcare Interoperability Resources (FHIR). We will use a stepped-wedge, cluster randomized design across
three health systems and 10 EDs. Specific aims: 1) Examine the impact of the nudge implementation strategy
(CDS tool + Nudge) on adoption of guideline-concordant CT ordering, 2) Determine the impact of the nudge
implementation strategy on identified behavioral barriers to adoption of guideline-concordant CT ordering, and
3) Confirm the clinical effectiveness of guideline-concordant CT ordering across diverse patient populations.
The proposed work is significant in its efforts to enhance health by preventing iatrogenic lung cancer and heart
disease caused by overtesting. It is innovative in its use of state-of-the-art technological methods and
assessment of causal mechanisms of nudge in CDS. Achieving the project’s objectives will advance the
science of implementation in emergency medicine and the application of nudges to provider decision-making.
Terms: <Accident and Emergency department><Address><Adoption><American><Architecture><Asian group><Asian individual><Asian people><Asian population><Asians><Behavior assessment><Behavioral><CAT scan><CT X Ray><CT Xray><CT imaging><CT scan><Cancers><Cardiac Diseases><Cardiac Disorders><Caring><Cessation of life><Chest><Clinical><Clinical effectiveness><Communication><Computed Tomography><Consent><Death><Decision Making><Development><Diagnosis><Diagnostic tests><Electronic Health Record><Emergency Department><Emergency Medicine><Emergency room><Engineering / Architecture><Enrollment><Ethnic Origin><Ethnicity><Evidence based practice><Exposure to><FHIR><Fast Healthcare Interoperability Resources><Fear><Fright><Geography><Goals><Guidelines><Health><Health system><Heart Diseases><Hispanic Populations><Hispanic group><Hispanic individual><Hispanic people><Hispanics><Hybrids><Iatrogenesis><Image><Incidental Findings><Inequity><Interview><Malignant Neoplasms><Malignant Tumor><Malignant Tumor of the Lung><Malignant neoplasm of lung><Methods><Organ Donations><Outcome><Patients><Physicians><Positive Reinforcements><Predicting Risk><Probability><Proctor evaluation model><Proctor framework><Proctor multi-level outcomes framework><Proctor multilevel outcomes framework><Proctor process outcomes><Proctor taxonomy><Professional Organizations><Protocol><Protocols documentation><Provider><Pulmonary Cancer><Pulmonary Embolism><Pulmonary malignant Neoplasm><Race><Races><Radiation><Randomized><Recommendation><Reporting><Risk><Scanning><Site><Structure><Suggestion><Survey Instrument><Surveys><Technology><Testing><Thorace><Thoracic><Thorax><Time><Tomodensitometry><United States><Work><X-Ray CAT Scan><X-Ray Computed Tomography><X-Ray Computerized Tomography><Xray CAT scan><Xray Computed Tomography><Xray computerized tomography><adoption by clinician><adoption by healthcare providers><adoption by physician><adoption by provider><behavioral assessment><behavioral economics><budget impact><cardiovascular disease risk><cardiovascular disorder risk><care as usual><catscan><clinical decision support><clinical efficacy><clinical predictors><clinician adoption><cluster randomized design><cognitive burden><cognitive load><college><collegiate><community setting><computed axial tomography><computer tomography><computerized axial tomography><computerized tomography><cost><cost effectiveness><design><designing><developmental><electronic health care record><electronic health medical record><electronic health plan record><electronic health registry><electronic medical health record><enroll><evidence base><forecasting risk><framework by proctor><heart disorder><high risk><iatrogenic><iatrogenically><iatrogenicity><imaging><implementation intervention><implementation science><implementation strategy><improved><innovate><innovation><innovative><innovative technologies><insight><internet based platform><internet platform><lung cancer><malignancy><neoplasm/cancer><new approaches><non-contrast CT><noncontrast CT><noncontrast computed tomography><novel approaches><novel strategies><novel strategy><patient population><peer><physician adoption><pilot test><predict risk><predict risks><predicted risk><predicted risks><predicting risks><predictive risk><predictive tools><predicts risk><prevent><preventing><primary outcome><proctor conceptual model><proctor implementation><proctor model><professional association><professional membership><professional society><provider adoption><provider-level adoption><racial><racial background><racial origin><randomisation><randomization><randomly assigned><risk prediction><risk predictions><risk stratification><strategies for implementation><stratify risk><support tools><theories><tool><treatment as usual><usual care><web based platform><web based system><web enabled platform><web platform>