Addressing Overuse by Nudging Patients and Clinicians Toward Shared Decision-Making

Overuse of imaging tests, laboratory tests, and medications appears to be rampant in US medicine and society.The causes are many and complex but include physicians practicing in time-pressured environments, using electronic health records that facilitate ordering, and seeing patientsunderstandably dissatisfied with a fragmented health care system-who consume unvetted healthrelated information and misinformation on social media, sometimes seeking quick, simple fixes.Physicians and patients often overestimate the benefits and underappreciate the potential downstream harms from unconsidered laboratory testing, imaging, and medications.Our group continues to study clinician-directed nudges-often electronic health record based, often using audit and feedback-to discourage use of inappropriate, low-value, or high-risk medications, such as antibiotics, opioids, and sleep medications. 1,2To address opioid and benzodiazepine overuse, the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services have advocated that clinicians engage in a shared decision-making approach. 3,4Although shared decision-making is essential for fostering patient engagement and trust, it requires time and rapport, both of which are often limited in clinical practice. 5Intervening directly with patients who are chronically using high-risk medications, such as benzodiazepines, is another approach.In this issue of JAMA Network Open, Humphreys and colleagues 6 describe a randomized clinical trial of Eliminating Medications Through Patient Ownership of End Results, electronically delivered, or EMPOWER-ED, a patient self-management intervention to reduce or stop benzodiazepine use. 7In this study, 161 patients (mean [SD] age, 61.9 [13.7] years) with long-term benzodiazepine dependence use who had a median 7-item Generalized Anxiety Disorder Scale score of 9 (moderate anxiety) and averaged taking the equivalent of just over 20 mg of diazepam per day were randomized to receive EMPOWER-ED or not.After 6 months, 12.2% of intervention participants stopped taking benzodiazepines compared with 2.5% in the control group (number needed to treat, 10).There were no differences between groups in patient-reported outcomes for physical health, mental health, anxiety, or sleep.EMPOWER-ED, an adaptation of a pharmacy-based intervention, is a low-cost, potentially scalable, patient-activating tool.The intervention helps patients understand the risks and benefits of benzodiazepines, includes patient stories, examines safe self-tapering strategies, and can enable patients to come to clinic visits better informed and prepared to make a change.EMPOWER-ED also provides patients with therapeutic alternatives-something both patients and physicians need-and links to mobile applications to help with sleep or anxiety.The EMPOWER-ED intervention and study were strong, but some questions and challenges remain.Patients' perspectives on the use of these materials will be important.How did patients access the intervention?What elements of the intervention worked best?Did accessing this intervention lead patients to more discussions with their primary care physicians, thus strengthening the physician-patient relationship?How can we adapt these materials to meet the needs of a diverse population?More information about the indications for benzodiazepines and, among patients tapering or stopping benzodiazepines, changes in anxiety, sleep, health, and use of other medications would clarify the use and usefulness of EMPOWER-ED and let clinicians and patients know what to expect.