# Preliminary Implementation of an Informational Nudge to Improve Heart Failure Prescribing

> **NIH VA I21** · SOUTHERN ARIZONA VA HEALTH CARE SYSTEM · 2024 · —

## Abstract

Background: VA has experience with strategies to promote guideline-concordant heart failure
(HF) care but there is a need for greater innovation. Nudge theory is a field within behavioral
science that focuses on the psychology of decision-making and offers a novel solution to improve
health care. In this proposed study, we will evaluate two nudge interventions, alerts and peer
comparison feedback, that exploit several biases which constitute the theoretical basis
supporting behavioral change.
Significance: The HF treatment gap is serious, costly, and all-too-common (low adoption of
SGLT2i and MRAs). The rates of HF guideline-directed therapy have stagnated in the VA. Our
group and others have reported that 34,000 and 21,000 deaths could be averted with optimal
implementation of SGLT2i and MRAs, respectively, in the U.S.
Innovation & Impact: We will test the effectiveness of a multicomponent nudge strategy
(alert + peer comparison) which are rarely conducted compared to single component strategies.
Only 10% of clinical-directed nudge interventions in the literature are multicomponent, and
none were identified in the VA. This study will create knowledge on how to combine these
different strategies which are needed to advance the field further and efficiently allocate VA
resources. This study targets an HF treatment gap (SGLT2 and MRA) in which no prior nudge
studies have demonstrated efficacy. This proposal utilizes an implementation science
(CDS/PRISM) approach to develop nudge strategies which is needed to ensure optimal
effectiveness, implementation, and sustainability.
Specific Aims:
1) Conduct a formative evaluation to develop two nudge strategies, an informational alert and
 peer comparison feedback, to encourage clinicians to prescribe MRA and SGLT2 inhibitors.
2) Evaluate preliminary outcomes of the two nudge strategies using the RE-AIM framework.
 a) Evaluate the preliminary effectiveness of the alert and peer comparison strategies in a
 four-group design.
 b) Evaluate the implementation outcomes of the two nudge strategies.
 i) We will report the following PRISM/RE-AIM outcomes: intervention, recipients,
 external environment, infrastructure, Reach, Adoption, and Implementation.
Methodology: This is a single-center pilot study. For Aim 1, we will conduct key stakeholder
interviews and focus groups of clinicians to assess barriers and facilitators to SGLT2 and MRA
prescribing and to refine the prototype nudges. For Aim 2, clinicians will be randomized to one
of four arms: usual care, informational alert, peer comparison feedback, and combination of
alert and peer comparison. We will compare Effectiveness, defined as new prescription of
SGLT2 or MRA within 30 days, in the three intervention versus control groups. We will also
report other outcomes including safety, Reach, Adoption, and Implementation.
Next Steps/Implementation: We will plan to test the nudge strategies in a broader trial of
multiple VAMCs using information gained from this ...

## Key facts

- **NIH application ID:** 10846609
- **Project number:** 5I21HX003613-02
- **Recipient organization:** SOUTHERN ARIZONA VA HEALTH CARE SYSTEM
- **Principal Investigator:** Sandesh Dev
- **Activity code:** I21 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2023-05-01 → 2025-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10846609

## Citation

> US National Institutes of Health, RePORTER application 10846609, Preliminary Implementation of an Informational Nudge to Improve Heart Failure Prescribing (5I21HX003613-02). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10846609. Licensed CC0.

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