From: Rosalie Wyonch
To: Canada’s health system administrators
Date: February 5, 2020
Subject: Nudging Health: The Good, the Bad and the Ugly
Behavioural “nudges” can influence the choices that individuals and healthcare professionals make. A nudge changes the context of decision-making to subtly influence resulting choices. In healthcare, they can encourage appropriate prescribing practices and influence patients to better adhere to treatment plans.
Nudges can exert a positive influence. For example, adapting ordering procedures and requisition forms to make them more restrictive in their “default” options can induce appropriate prescribing and testing behaviour: family physicians provided with a modified basic shortcut menu for ordering laboratory tests, where some tests were not included, showed significant decreases in the volume of test orders.
Similarly, audit and feedback information can change physician prescribing and test-ordering behaviour, but there are limits. A 2018 study found that simply sending a letter to primary care physicians informing them of potentially dangerous side-effects, and that their prescribing rates were higher than their peers, was effective at reducing prescription rates.
The study targeted primary care physicians prescribing an antipsychotic medication with potentially dangerous side effects in elderly patients and found that new prescriptions dropped by 24 percent over two years.
Yet, other research has shown that audit and feedback information had no effect on physician laboratory test ordering practices in the hospital setting, possibly due to physicians not meaningfully engaging with the information.
A combination of audit and feedback with education has been shown to be effective in addressing high-volume laboratory test users – resulting in an 8 percent reduction in utilization that persisted for at least two years.
Patient behaviour can also be beneficially influenced by nudging. Nudging patients with heart disease to take their daily statins resulted in better adherence than those who did not receive reminders. Similarly, patients who make a commitment to adhering to their prescription instructions, along with receiving information warning them about personal adverse consequences if they did not, were significantly more likely to take their medications as prescribed.
There are, however, limits to influencing patient behaviour as well – an intervention including lottery incentives and social supports found no effects on repeated hospitalizations, medication adherence or total cost.
Nudges can also be used less helpfully. A US software records company recently agreed to pay $145 million to resolve civil and criminal cases related to a nudge alert it built into an electronic records management tool to influence physicians to inappropriately overprescribe opiates.
Behavioural interventions can nudge patients and healthcare providers toward particular decisions. It is imperative that health system administrators and policy makers investigate how decisions are being made and possibly influenced and make the necessary adjustments to ensure they will not lead to unnecessary tests, treatments and further unintended consequences. They should also implement policies and procedures such as audit and feedback information combined with educational interventions to meaningfully influence patient and physician behaviour for the better.
Rosalie Wyonch is a Policy Analyst at the C.D. Howe Institute.
To send a comment or leave feedback, email us at blog@cdhowe.org.
The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.
