Nudge strategy leads to 15-fold increase in naltrexone prescriptions
Issue
Millions of Americans struggle with alcohol use disorder, but few take advantage of a medication called naltrexone, which helps control cravings and has been shown to reduce heavy drinking.
Emergency departments see patients with a range of problems stemming from alcohol use and could be a useful setting to connect patients with treatment.
Intervention
A Penn research team sought to make it easier for emergency departments to flag patients who could benefit from starting naltrexone, and they developed a nudge intervention with 3 key components:
First Component
Triage nurses were prompted to ask patients if they “struggled” with alcohol in the past week (language suggested by patient stakeholders).
Second Component
If the answer was yes, an electronic health record banner nudged clinicians to talk to the patient about naltrexone. Clicking the banner gave more information:
- A clinical pathway for managing alcohol use disorder provided information on things like outpatient care, inpatient withdrawal management, target populations, initial dosing, and more.
- A motivational interviewing script helped clinicians communicate with the patient by asking questions like: What are the benefits of drinking less? What makes it hard? How interested are you in cutting back?
Third Component
If the patient was interested, the banner linked to a discharge alcohol order set with a default pre-populated naltrexone prescription and easy-to-follow instructions for patients.
Results
The intervention was implemented at 4 hospitals in the University of Pennsylvania health system, and two other hospitals served as controls. The research team looked at nearly 660,000 patient encounters: 442,000 at intervention hospitals and 217,000 at control hospitals. About 2.0% of patients were discharged with an alcohol-related diagnosis—the target population for the intervention.
At intervention hospitals, only 13 (0.2%) of these patients received a naltrexone prescription during the 2.5-year baseline, compared with 81 (3.2%) during the 10 months when nudges were fully implemented. At control hospitals, zero patients received a prescription at baseline and only 4 (0.3%) did during the 10-month intervention period.
After adjusting for other factors, patients at intervention hospitals were 14.6 times more likely to be discharged with a naltrexone prescription.
A difference-in-differences analysis found a 2.9 percentage-point greater increase in naltrexone prescribing at intervention hospitals.
Also, the number of unique clinicians prescribing naltrexone increased six-fold compared to baseline at the intervention hospitals, suggesting that prescribing spread to more clinicians rather than being driven by only a small group of prescribers.
“Emergency departments offer a critical and overlooked point of intervention for initiating treatment for alcohol use disorder and alcohol misuse, as many patients present with acute alcohol-related harms, but few are offered treatment for the underlying cause. Scalable, pragmatic strategies are essential to narrow treatment gaps. Our results suggest that combining universal screening with targeted electronic health record prompts is a feasible and effective implementation strategy to expand treatment for alcohol use disorder and alcohol misuse in emergency departments settings,” the study authors wrote.
Read the paper, led by Dr. Jeff Ebert, in the Annals of Emergency Medicine.
Find media coverage in STAT here. Dr. Kit Delgado is quoted in the story.