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 study to inform implementation. We will work with our partners in National Cardiology and PBM Academic Detailing to disseminate our findings, and they will be included in periodic stakeholders’ meetings during the study.

This study addresses a critical gap in quality of care for Veterans with heart failure (HF). Only 1/3 or fewer eligible Veterans are receiving SGLT2 inhibitors and mineralocorticoid receptor antagonists, both medications that save lives and prevents HF hospitalizations. We will combine insights from behavioral science and quality improvement science to create two types of ‘nudges’ – informational alerts and peer comparison feedback - to increase prescribing of these medications. We will compare the effect of these two nudge strategies alone and in combination compared to usual care. This project will develop simple, scalable, and low-cost strategies to improve the health of Veterans with HF.