When Nudges Don't Budge: A Mixed Methods Study of Why EHR-Based Deprescribing Nudges Failed to Change Provider Behavior.

Background: De-implementation-reducing low-value or harmful care-is critical but often difficult in practice. Nudges via clinical decision support (CDS) tools in electronic health records aim to promote guideline-concordant care, but their effectiveness is mixed. In a randomized trial, we tested CDS nudges to support deprescribing glycemic medications in older adults, aligned with Choosing Wisely guidelines. Despite prior success elsewhere, the intervention had limited impact. The current study evaluated potential reasons why the EHR-based nudges to encourage guideline-based, relaxed glycemic control for older adults with Type 2 Diabetes were not effective in influencing clinician behavior. Methods: We conducted a retrospective cohort analysis of EHR data from 67,412 alerts issued to clinicians, promoting different types of glycemic control, including reducing metformin, switching from non-metformin medications to metformin, and discontinuing medication. Comments left by providers on 779 of those firings were coded and thematically analyzed by two authors. Logistic and multinomial logistic regressions were performed to understand the contexts behind the lack of nudge effectiveness at the alert, encounter, patient, and physician levels. Results: Out of 67,412 alerts, providers commented in only 1.15% of cases. When they did, they were about 10.7% more likely to act on the alert, but comments were mostly negative (3.28 times more likely). Feedback highlighted three themes: disagreement with guidelines (most common), poor alert fit in workflow, and patient reluctance to change medications. Logistic regressions showed providers were less likely to act on alerts with multiple triggers and more likely to leave negative comments. Multinomial models linked rejection themes to patient and medication traits, noting less rejection related to workflow in patients with limited life expectancy. Disparities in engagement were found, with female providers, patients, and socially vulnerable individuals less likely to comment. Conclusion: These findings highlight barriers to de-implementation via CDS. Provider disagreement, misaligned alerts, and patient resistance hinder effectiveness. Low engagement and negative feedback suggest nudges alone may not change behavior without integration into routines. Engagement variation stresses the need for tailored strategies. Future work should refine nudge design to address complexity, align with provider roles, and include patient-centered approaches. Trial registration: The NYU School of Medicine Institutional Review Board (i17-01308) approved the trial, which has the clinicaltrials.gov ID NCT04181307 (https://clinicaltrials.gov/study/NCT04181307), with date of first record on November 26, 2019.