Pilot Trial of a Behavioral Economics-Informed Clinical Decision Support Alert to Improve Inpatient Tobacco Use Treatment Rates

Abstract Introduction Evidence-based tobacco use treatment (TUT) improves clinical outcomes, yet few clinicians initiate TUT for hospitalized patients who smoke. Clinical decision support (CDS) tools embedded in electronic health records (EHRs) offer opportunities to guide clinicians toward desired behaviors. CDS alerts informed by behavioral economics (BE-CDS) may increase TUT by presenting preselected orders and requiring justification to opt out. We conducted a pilot study to evaluate the impact of a BE-CDS alert on TUT ordering for inpatients who smoke. Aims and Methods In a two-arm randomized trial at a large US academic health system, 50 clinicians were randomized to receive either a BE-CDS alert or a standard reminder encouraging inpatient pharmacotherapy and outpatient follow-up. Alerts were triggered upon chart entry for eligible patients. The primary outcome was the rate of any TUT-related order (medication, counseling, or referral). Clinician feedback on alert appropriateness and workflow impact was also collected. Results From June 2022 to December 2023, 635 inpatients met the inclusion criteria. There were no significant differences in rates of any TUT order (25.2% vs. 28.5%, p = .27), inpatient medication (17.2% vs. 18.4%, p = .62), or discharge medication (7.1% vs. 6.6%, p = .90). Referral to outpatient follow-up was higher in the BE-CDS group (8.4% vs. 3.3%; OR = 2.54, p = .01). Number of alerts delivered, and White patient race, were associated with increased TUT rates. Clinicians preferred the BE-CDS format but cited alert workflow placement as more influential than alert design. Conclusions BE-CDS improved referral rates but did not significantly impact overall TUT. Further research should explore deeper drivers of inpatient TUT decision-making. Trial Registration ClinicalTrials.gov. NCT04738643. Registered February 4, 2021. https://clinicaltrials.gov/study/NCT04738643. Implications Compared to the standard electronic practice reminders, behavioral economics-informed clinical decision support alerts increased referrals to outpatient tobacco use treatment services for inpatients who smoke, but did not increase tobacco treatment intervention rates during the inpatient stay. Several variables appear to influence rates of tobacco use treatment, including the number of alert interactions and patient race. This pilot study suggests that the barriers to inpatient tobacco interventions may be complex and therefore insensitive to simple behavioral economic nudges.