“Nudging” Providers in the Right Direction

For some time now, those interested in promoting safety in healthcare (such as our recent visitors from the Solutions for Patient Safety collaborative) have recognized that creating a high reliability environment and a culture of safety require a focus on the systems within which people operate, rather than on the individuals themselves.  Checklists, hard stop alerts, pre-filled syringes, all are examples of system design that “nudge” us (gently or firmly) away from things that might harm patients.

But when it comes to the effectiveness domain of quality, we still tend to focus on individual solutions – e.g., publishing systematic reviews or clinical guidelines, education – in the hope that providers will do the right thing. In reality, though, translating research into practice tends to be slow, sometimes painfully so.  Some recent publications shed some light on some of the barriers.  Pediatrician and New York Times columnist Pauline Chen wrote about barriers to clinicians acting on comparative effectiveness research results.  Citing a study in Health Affairs, she notes several factors that impede the ability of such studies to change practice: financial incentives that promote the status quo; limited applicability of study results to real world populations; ambiguity of study results (e.g., conflicting studies, subgroup differences); cognitive biases (e.g., the belief that more care or more expensive care equals better care); and limited use of decision support tools.

Changes in the health care payment environment may alter the financial incentives, and ongoing efforts to improve the design and conduct of comparative effectiveness research, such as those sponsored by the Patient Centered Outcomes Research Institute, will address the second two points.  Another recent article in Health Affairs sheds some light on the issue of cognitive biases.  Drawing on experience with behavioral economics, the authors discuss the two cognitive systems that affect behavior – the automatic and the reflective.  While the latter is driven by rational thought, the former is driven by heuristics, mental short-cuts that allow us to react rapidly to an onslaught of multiple, simultaneous inputs.  While they often serve us well and keep our brains from being overwhelmed, these heuristics are subject to a variety of biases and errors.  One example is “availability bias,” where things we have encountered most recently assume greater importance than they warrant based on actual probability.  The point of the article is that, if we hope to change clinical practice behavior, we cannot rely strictly on education – which utilizes the reflective system of processing – and instead use approaches that acknowledge and account for the biases inherent in the automatic thought processing we all use in our day-to-day practice.  For instance, behavior is often driven by perceived norms; we want to do what others in a similar situation would do. (“I believe most people would get a CT in a patient with a new onset seizure.”) The problem is, we don’t always know what those norms really are. (How often are CT’s actually done in such patients?)  If we knew what the norms are, we might be more inclined to change what we do to conform.  Another example is how our perception is altered by the messenger.  They cite a study where 82% of physicians said they trusted a guideline from their professional organization, while only 6% supported the same guideline said to come from an insurer.

One particularly important behavioral promoter of change is making the desired activity the default.  Enrollment in retirement plans and organ donation are both dramatically higher when someone has to opt out rather than opt in.  Similarly, generic prescribing is higher when that is the default.  This is a system change that can be used to drive evidence-based practice.  So is decision support, the fifth barrier to translating research into practice.  Building the evidence into the same tools we use for documenting and ordering is an important way to promote the use of that evidence.  Taking a systems approach will help as we attempt to improve quality in all of its domains, including effectiveness and efficiency as well as safety.

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