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How simple questions and behavioral nudges are improving care

If opioid use disorder is a disease, then why not treat it with medicine?

Although it is a simple question, it has often been a fraught one. Attitudes toward opioid use are decidedly not uniform, even in the medical community, which has hampered the ability to curb an epidemic that is constantly setting deadly records.

However, a few years ago, clinicians and researchers in the Penn Medicine community set out to treat opioid use disorder more consistently with medications, focusing largely on buprenorphine, which soothes cravings for opioids and treats withdrawal symptoms. The results, led largely by members of what is now the Penn Medicine Center for Addiction Medicine and Policy (CAMP), have been stark. Among their accomplishments: Dramatically increasing its use in emergency departments and significantly boosting engagement with opioid treatment well after initial hospital visits

In other words, some seemingly simple interventions have saved lives. 

Amid the COVID-19 pandemic in 2020, Jeanmarie Perrone, MD, a professor of Emergency Medicine in the Perelman School of Medicine and CAMP founding director, began noticing a significant uptick in alcohol-related mortality. She again asked that question, but a little differently: Why not treat alcohol use the same way we’ve been treating opioid use?

Now, as part of the Penn Medicine Nudge Unit’s annual pilot program accelerator, Perrone and her colleagues will attempt to treat more patients who have alcohol use disorder (AUD) with naltrexone, a medication that blocks cravings in a way and has been shown to significantly reduce heavy drinking days.

Using a nudge to make evidence-based treatments stick 

 The alcohol use treatment project is one of four chosen to use the concept of “nudging”—a behavioral science technique in which people are gently influenced toward making positive decisions—to improve care delivery. 

“The use of naltrexone for patients struggling with alcohol use is a clear case of an evidence-to-practice gap where a nudge could have significant impact,” said Kit Delgado, MD, an associate professor of emergency medicine and epidemiology and the director of the Nudge Unit. “There are reams of evidence showing a proven benefit, but it (naltrexone) is barely prescribed for patients being discharged from the emergency department, which may be the only touchpoint with the health care system. Increasing use and connecting patients to treatment can not only reduce heavy drinking days but reduce complications from alcohol and reduce ED visits and hospitalizations.”

Perrone, for example, hopes the shift from simply encouraging that people “drink less” to treating AUD with medicine will affect changes like drops in alcoholic liver disease and decreases in alcohol-related incidents like falls or car crashes. 

“We want to use our nudge to prompt clinicians to consider starting naltrexone with the first prescription happening upon discharge from the emergency department,” Perrone said. “Since I learned of the evidence supporting naltrexone, I have started asking any patient with alcohol use whether they had ever been offered a medication to curb their alcohol intake. They have been overwhelmingly interested—and unaware—which sets the stage for a potentially successful intervention.”

The goal is harm reduction. Because naltrexone can be taken on an “as-needed” basis, such as to curb alcohol intake at parties or social events, it potentially offers people a more realistic opportunity to control their drinking.

Re-evaluating an automatic task 

As in the past, the Nudge Unit’s pilot projects seek to make improvements across a variety of focus areas in medicine. And that requires asking more questions, such as: Are we hurting someone by doing this? 

Elizabeth Kravitz, MD, a resident in Obstetrics and Gynecology, for example, is leading a project that addresses the administration of urine drug screening among people giving birth. While these screenings can be beneficial to determine if certain symptoms can be explained chemically and treated accordingly, in most hospitals, the screening can be ordered by almost any clinician for any reason, even if it may not be helpful for their treatment. The results, though, can be devastating, with the potential for a person’s children being taken from them or child abuse charges being filed for something as marginal as trace amounts of marijuana being detected. Often, these screenings happen without patients knowing they are being ordered.

“In many places, there is no protocol for ordering this,” said Kravitz. “It could be ordered because a patient was ‘acting funny’ or because someone simply has not received prenatal care. This ends up being a big deal because of the social ramifications, and the data across the country shows that Black families are much more likely to become separated as a result of these screenings.”

Through the work of Abike James, MD, MPH, an associate professor of Obstetrics and Gynecology, Penn Medicine has guidance in place to be more careful about urine drug screening orders. But Kravitz, along with James and their team, which includes collaborators across many specialties and the Advocacy for Racial and Civil Justice Clinic at Penn Carey Law School, hope to use a nudge system built into the electronic health record—which will include an accountable justification to click through—to encourage care team members to slow down and be much more thoughtful about ordering screenings.

Through this, they hope to achieve a 100 percent consent rate among patients. They also hope the project will contribute to larger efforts to reduce disparities along racial and ethnic lines, and, like many of these other projects, work to spread this system to other hospitals in Philadelphia and beyond.

“Our hope is that this will help people to understand the implications of what they’re doing,” Kravitz said. “Some may be brand new and just view this as part of the checklist. But we want to make it something that isn’t automatic because it is so impactful.”

Improving patient service 

The remaining nudge projects encompass one question: How can we improve patients’ experience?

One, led by Amanda Binkley, PharmD, BCIDP, AAHIVP, an infectious diseases clinical pharmacy specialist, addresses the many patients who have penicillin allergies but have a surgical procedure that requires an antibiotic to prevent a post-operative infection. She noticed that many patients would benefit from receiving a medication called cefazolin, but it is often not prescribed because of a concern that this drug may cause an allergic reaction among patients with penicillin allergies, even though the evidence strongly suggests this is not the case. 

There is a large opportunity since 1 out of 10 patients undergoing surgery have a penicillin allergy and rates of post-operative infections and readmissions much higher in these patients. As such, Binkley and her team proposed a project nudging more physicians to use cefazolin, revisit drug allergy alerts for cefazolin, and potentially protect more patients from infections related to their surgeries.

“The Antimicrobial Stewardship team at Penn Presbyterian had already started this work for patients undergoing orthopedic surgeries,” Binkley explained. “We applied for the nudge pilot program in order to create a system-based, sustained way to improve preoperative antibiotic prescribing and to expand to other surgical service lines and all Penn Medicine hospitals.”

The last new pilot focuses on improving access to translators among people giving birth at Penn Medicine hospitals, with an eye toward cutting into health disparities seen among those who aren’t fluent in English.

Elizabeth Kane, MD, a resident in Family Medicine and Community Health, is the team lead for this project, which will seek to prompt clinicians to use interpreters for patients with a preferred language other than English and make it more likely that clinicians will access available translator services. (Recently, adding more Spanish-language interpreters was among the solutions offered as part of an award-winning initiative to improve Hispanic patients’ postpartum outcomes at Chester County Hospital.) “We would hope that in one year we will find that the overall use of interpreters increases, which will have a positive impact on patient outcomes and satisfaction,” Kane said. “Our hope is that, in 10 years, Penn is recognized as a leader in providing language-concordant care and systems are put in place to support patients with low English proficiency in all phases of care, including when calling the offices or receiving patient instructions.”

Each of these projects will start with an intensive period in which the project teams and Nudge Unit staff conduct interviews, observe patterns of care, and examine baseline data to pinpoint key problems with existing processes. Then the teams will discuss multiple potential solutions and rapidly assess promising nudge interventions to test, implement, and scale in collaboration with health system partners. 

“Over the past year and half, we’ve received applications from more than 110 Penn Medicine care teams for assistance from the Nudge Unit,” Delgado said. “We’re fortunate to be able to work on important problems with amazing care teams in which potential solutions can have significant impact at scale for improving high-value and equitable care for patients.”

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