Evaluating clinicians preferences for nudge design to optimize guideline-directed medical therapy for heart failure
J G Valk, C Jansen, M Van Den Heuvel, A John, M Tabak, M J SchuuringAbstract
Background
Guideline-directed medical therapy (GDMT) substantially improves clinical outcomes for patients with heart failure (HF). Despite clear recommendations, many HF patient do not receive GDMT. Previous research has shown that nudging clinicians can improve medication prescription, however optimal nudge design to improve HF GDMT prescription is unknown.
Purpose
To identify the optimal design for clinical nudges to support GDMT prescription for HF.
Method
A web-based questionnaire was developed to evaluate clinician preferences for clinical nudge designs used in the ADMINISTER II study. The questionnaire consisted of ten binary-choice questions, presenting two versions of a clinical nudge (Figure 1). First a reference version, based on the predecessor of the ADMINISTER II study, included clinical status, latest telemonitoring measurements, laboratory values, HF medication prescriptions and HF guideline information. Second an alternate version incorporating a modification in one of five categories: Health status based on Kansas City Cardiomyopathy Questionnaire (KCCQ) content, additional context, placement of guideline information, highlighted content, and conciseness. The questionnaire was structured around two cases with differing HF severity, each associated with five questions. 43 Clinicians involved in the ADMINISTER II study were invited to participate. Consensus was defined as ≥75% agreement of clinicians.
Results
The response rate of this study was 56%, with 24 clinicians (15 cardiologists, seven cardiology residents, and two physician assistants) finishing the questionnaire, 33% female, ten HF-oriented clinicians. 4/10 questions reached consensus of ≥75%. For both cases, over 87% of clinicians preferred a comprehensive nudge that includes all sections of the reference nudge. Telemonitoring trend information was preferred by 79% of respondents. While 83% of respondents preferred additional KCCQ content for the second case, no consensus could be reached since only 50% preferred KCCQ content in the first case. Intra-clinician variability was high throughout the questionnaire, with 32% of clinicians changing answers to similar questions across cases, indicating case dependency. Both questions regarding highlighting were not preferred, reaching 71% agreement. However, two clinicians noted that the questions regarding highlighting were unclear, if their data were excluded, consensus would have been reached.
Conclusions
This web-based questionnaire among clinicians achieved an above average response rate (56%) in comparison to literature. Consensus was reached for a comprehensive nudge including additional telemonitoring trend information. Case dependency and inter-clinician disagreement limit additional identification of optimal nudge design. Studies to investigate case dependencies could further improve nudge design to support GDMT prescription for HF.Screenshot from the questionnaireFor image description, please refer to the figure legend and surrounding text.Agreement percentage of cliniciansFor image description, please refer to the figure legend and surrounding text.