When Nudges Don't Budge: A Mixed Methods Study of Why EHR-Based Deprescribing Nudges Failed to Change Provider Behavior
Abstract
BACKGROUND: De-implementation-reducing low-value or harmful care-is critical but often difficult in practice. Nudges via clinical decision support (CDS) tools in electronic health records aim to promote guideline-concordant care, but their effectiveness is mixed. In a randomized trial, we tested CDS nudges to support deprescribing glycemic medications in older adults, aligned with Choosing Wisely guidelines. Despite prior success elsewhere, the intervention had limited impact. The current study evaluated potential reasons why the EHR-based nudges to encourage guideline-based, relaxed glycemic control for older adults with Type 2 Diabetes were not effective in influencing clinician behavior.
METHODS: We conducted a retrospective cohort analysis of EHR data from 67,412 alerts issued to clinicians, promoting different types of glycemic control, including reducing metformin, switching from non-metformin medications to metformin, and discontinuing medication. Comments left by providers on 779 of those firings were coded and thematically analyzed by two authors. Logistic and multinomial logistic regressions were performed to understand the contexts behind the lack of nudge effectiveness at the alert, encounter, patient, and physician levels.
RESULTS: Out of 67,412 alerts, providers commented in only 1.15% of cases. When they did, they were about 10.7% more likely to act on the alert, but comments were mostly negative (3.28 times more likely). Feedback highlighted three themes:…
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