Lauffenburger Julie C, DiFrancesco Matthew F, Barlev Renee A, Robertson Ted, Kim Erin, Coll Maxwell D, Haff Nancy, Fontanet Constance P, Hanken Kaitlin, Oran Rebecca, Avorn Jerry, Choudhry Niteesh K
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
ideas42, New York, NY, United States.
JMIR Res Protoc. 2022 Apr 27;11(4):e31464. doi: 10.2196/31464.
Gaps between rational thought and actual decisions are increasingly recognized as a reason why people make suboptimal choices in states of heightened emotion, such as stress. These observations may help explain why high-risk medications continue to be prescribed to acutely ill hospitalized older adults despite widely accepted recommendations against these practices. Role playing and other efforts, such as simulation training, have demonstrated benefits to help people avoid decisional gaps but have not been tested to reduce overprescribing of high-risk medications.
This study aims to evaluate the impact of a simulation-based training program designed to address decisional gaps on prescribing of high-risk medications compared with control.
In this 2-arm pragmatic trial, we are randomizing at least 36 first-year medical resident physicians (ie, interns) who provide care on inpatient general medicine services at a large academic medical center to either intervention (simulation-based training) or control (online educational training). The intervention comprises a 40-minute immersive individual simulation training consisting of a reality-based patient care scenario in a simulated environment at the beginning of their inpatient service rotation. The simulation focuses on 3 types of high-risk medications, including benzodiazepines, antipsychotics, and sedative hypnotics (Z-drugs), in older adults, and is specifically designed to help the physicians identify their reactions and prescribing decisions in stressful situations that are common in the inpatient setting. The simulation scenario is followed by a semistructured debriefing with an expert facilitator. The trial's primary outcome is the number of medication doses for any of the high-risk medications prescribed by the interns to patients aged 65 years or older who were not taking one of the medications upon admission. Secondary outcomes include prescribing by all providers on the care team, being discharged on 1 of the medications, and prescribing of related medications (eg, melatonin, trazodone), or the medications of interest for the control intervention. These outcomes will be measured using electronic health record data.
Recruitment of interns began on March 29, 2021. Recruitment for the trial ended in Q42021, with follow-up completed by Q12022.
This trial will evaluate the impact of a simulation-based training program designed using behavioral science principles on prescribing of high-risk medications by junior physicians. If the intervention is shown to be effective, this approach could potentially be reproducible by others and for a broader set of behaviors.
ClinicalTrials.gov NCT04668248; https://clinicaltrials.gov/ct2/show/NCT04668248.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/31464.
理性思维与实际决策之间的差距日益被视为人们在情绪高度紧张状态（如压力状态）下做出次优选择的一个原因。这些观察结果可能有助于解释为什么尽管有广泛认可的反对这些做法的建议，但高风险药物仍继续被开给急性病住院的老年人。角色扮演和其他努力，如模拟培训，已证明有助于人们避免决策差距，但尚未经过测试以减少高风险药物的过度处方。
本研究旨在评估一项基于模拟的培训计划与对照组相比，对解决决策差距对高风险药物处方的影响。
在这项双臂实用试验中，我们将至少36名在大型学术医疗中心的住院普通内科服务中提供护理的一年级住院医师（即实习生）随机分为干预组（基于模拟的培训）或对照组（在线教育培训）。干预包括一次40分钟的沉浸式个人模拟培训，在他们住院服务轮转开始时，在模拟环境中进行基于现实的患者护理场景。该模拟聚焦于老年人中3种高风险药物，包括苯二氮卓类药物、抗精神病药物和镇静催眠药（Z类药物），并专门设计用于帮助医生识别他们在住院环境中常见的压力情况下的反应和处方决策。模拟场景之后是由专家主持人进行的半结构化汇报。试验的主要结局是实习生给65岁及以上入院时未服用其中一种药物的患者开具的任何高风险药物的剂量数。次要结局包括护理团队所有提供者的处方、出院时服用其中一种药物以及相关药物（如褪黑素、曲唑酮）的处方，或对照干预的目标药物的处方。这些结局将使用电子健康记录数据进行测量。
实习生招募于2021年3月29日开始。该试验的招募于2021年第四季度结束，随访于2022年第一季度完成。
本试验将评估一项基于行为科学原理设计的模拟培训计划对初级医生高风险药物处方的影响。如果该干预措施被证明是有效的，这种方法可能会被其他人复制，并应用于更广泛的行为。
ClinicalTrials.gov NCT04668248；https://clinicaltrials.gov/ct2/show/NCT04668248。
国际注册报告识别码（IRRID）：PRR1-10.2196/31464。
