Some types of nudges may promote guideline adherence
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Clinical nudges, when geared towards increasing the salience of information, providing feedback and implementing default order sets in electronic systems, were “generally effective” in promoting adherence to guidelines, researchers wrote.
However, the systematic review lacked data on the effectiveness of other types of nudges, including “anticipated error reduction, structuring of complex problems, and understanding mapping,” Onyi Nwafor, PhD, an assistant professor at the Bryan School of Business and Economics, University of North Carolina at Greensboro, and colleagues wrote in Social Science and Medicine.
“We also found that this literature is primarily focused on whether nudge interventions work, with little consideration for organizational issues such as cost-effectiveness, impact on health care workers, and disruptions of established workflows and routines,” the researchers continued.
Clinical nudges are “subtle changes in how choices are presented that can significantly influence a decision maker’s behavior in predictable ways without restricting choices,” Nwafor told Healio Primary Care.
For example, to reduce unnecessary antibiotic prescriptions, Nwafor said that physicians’ prescribing behaviors can be influenced by choices that are presented as preset options in an electronic order entry system.
“Pre-populating default settings in an electronic order entry system with preferred medications and doses is likely to promote desired prescription behavior because of what is known as a status quo bias — or decision makers’ innate preference for the current state of affairs (status quo) because of the perception that any change from the status quo is less advantageous,” she said.
But Nwafor warned that nudges may have “unintended impacts.” A previous review of 17 studies showed that EHR alerts intended to improve drug safety were overridden by clinicians between 49% to 96% of the time.
“While alerts can be generally effective in promoting adherence to guidelines, they could also result in alert fatigue, a phenomenon in which too many alerts may engender cognitive overload and subsequent failure of a decision maker to recognize the relevance of the alert to the current situation,” she said. “Alert fatigue can cause health care professionals to create potentially detrimental workarounds or overrides when using the EHR. It can also result in job dissatisfaction.”
Still, she said that health care workers can consider using nudges to improve guideline compliance rates. In addition, the data gleaned from the 83 studies that she and her colleagues analyzed may have broader implications for health care workers, such as COVID-19 vaccine hesitancy, Nwafor said.
“Evidence from our study suggests that the careful framing or design of communication messages in a way that emphasizes the benefits of getting vaccinated (ie, gains) rather than its risks (ie, losses) can be effective in promoting vaccine uptake among health care professionals,” she said. “Another communication strategy which our study found to be a generally effective nudge is the inclusion of peer-comparison information about the vaccination rates of other health care workers or organizations in an area.”
Moving forward, the researchers wrote that they hope to create a one-stop shop for evidence on nudges that can help policymakers and health care administrators create and administer interventions that “promote guideline-concordant behavior.”
References
Nwafor O, et al. Soc Sci Med. 2021;doi:10.1016/j.socscimed.2021.114321.
van der Sijs, H, et al. J Am Med Inform Assoc. 2006;doi:10.1197/jamia.M1809.