JMIR Publications

ABSTRACT

Background:

Gaps between rational thought and actual decisions are increasingly recognized as a reason that 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 recommendations against these practices being widely accepted. Role playing and other efforts have demonstrated benefits to help people avoid decisional gaps but have not been tested to reduce overprescribing of high-risk medications.

Objective:

To evaluate the impact of a simulation-based training program designed to avoid decisional gaps in prescribing of high-risk medications.

Methods:

In this two-arm pragmatic trial, we are randomizing first-year medical resident physicians (i.e., interns) providing care to older adults on inpatient general medicine services at a large academic medical center to either intervention (simulation-based training) or control (online educational training). The intervention consists of a 40-minute immersive individual simulation training at the beginning of their inpatient service rotation focused on high-risk medications, including benzodiazepines, anti-psychotics, and sedative hypnotics (“Z-drugs”). The simulation 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 semi-structured 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 ≥65 years who were not taking one of the medications upon admission. Secondary outcomes include prescribing by all providers on the care team, being discharged on one of the medications, and prescribing of related medications (e.g., melatonin, trazodone) or the medications of interest for the control intervention. These outcomes will be measured using electronic health record data.

Results:

Recruitment of interns began on March 29, 2021. We expect recruitment for the trial to end in Q32021, with follow-up completed by Q42021.

Conclusions:

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. Clinical Trial: Clinicaltrials.gov (NCT04668248)