7- Nudging” Toward High-Value Care

MODULE 8 | Section 7 of 11

“Nudging” Toward High-Value Care

WHAT’S A “NUDGE”?

“Nudge” is a theory of behavior change based on research in behavioral sciences, public health, psychology, and behavioral economics. The theory has been prominently advanced by Richard Thaler, who won the Nobel Prize in Economics in 2017.

 

Nudge relies on the use of positive reinforcement and indirect suggestions as ways to influence the behavior and decision-making of individuals or groups. This strategy contrasts with the usual methods used for behavior change such as education, legislation, or enforcement.

According to Thaler and Sunstein:

 

A nudge, as we will use the term, is any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, the intervention must be easy and cheap to avoid. Nudges are not mandates. Putting fruit at eye level counts as a nudge. Banning junk food does not.

“Nudges are not mandates. Putting fruit at eye level counts as a nudge. Banning junk food does not.”

“Nudge” strategies have been called “Libertarian Paternalism” because people are still free to choose, but somebody is attempting to influence choices in a way that will make choosers better off, as judged by themselves.

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TWO IMPORTANT LESSONS FROM NUDGE

  1. 1-Never underestimate the power of inertia.

 

  1. 2-There is no way to avoid nudging in some direction, and whether intended or not, these nudges will affect what people choose.

SOCIAL NUDGE STRATEGIES

There are a number of social nudge strategies, which provide insights into how to design interventions that could potentially alter behaviors toward high-value care.

INFORMATION ABOUT WHAT OTHERS ARE DOING

Conformity: drawing public attention to what others are doing

 

Framing: positive encouragement rather than warning

 
 

Correction of misperceptions with stats

 
 

PEER PRESSURE

Visual markers: positive recognition of desirable behaviors

 
 

Visual clues in the environment to remind of desirable behaviors

 
 
 

PRIMING

 
Asking for intentions, including when and how

Writing it down

 

 
 
 
 

An Example of “Nudging” in Health Care

In this randomized clinical trial2 in 5 outpatient primary care clinics, approximately half of the clinicians were randomized to complete and display poster-sized commitment letters featuring clinician photographs and signatures stating their commitment to avoid inappropriate antibiotic prescribing for acute respiratory infections. This is an example of “priming,” or asking for intentions and having people write it down, which is a nudge strategy that has been shown to be effective.

The posted commitment letter resulted in nearly a 20% absolute reduction in inappropriate antibiotic prescribing compared to control physicians. The authors concluded, “the effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts.”

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“Do we really want to list drugs for a given indication from A to Z, inadvertently guiding prescribers to choose a product that starts with a letter earlier in the alphabet when later options might be more effective, less expensive, or both?”

Mitesh Patel MD
Director of Penn Medicine Nudge Unit

REFERENCES

  1. 1-Thaler RH, Sunstein CR. Nudge: Improving Decisions about Health, Wealth, and Happiness. London, England: Penguin Books.

 

  1. 2-Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trialJAMA Intern Med. 2014;174(3):425–431.

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