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Can Behavioral Economics Help People Adopt Better Health Habits?

September 12, 2017
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Simple incentives may nudge patients, caregivers and clinicians to make more healthful choices.

Behavioral economics has helped electricity customers cut down on usage, new employees to start setting aside money for retirement from day one and, more recently, to change health care provider and patient behaviors.

The practice combines insights from psychology, economics and marketing to improve decision-making by individuals, says Jack Stevens, PhD, a clinical psychologist and principal investigator at the Center for Biobehavioral Health at Nationwide Children’s Hospital.

“In the health care field, certainly there are concerns about finding ways to save money and prevent unnecessary or ineffective care, but also concerns about optimizing people’s well-being,” says Dr. Stevens, an associate professor of Pediatrics at The Ohio State University College of Medicine and author of a commentary on behavioral economics in Pediatric Quality and Safety. “This can promote both objectives.”

Behavioral economics provides low-intensity nudges to help people make better decisions and avoid poor ones. But rather than dictate, the nudges include some degree of freedom of choice and control.

“In the health care field, certainly there are concerns about finding ways to save money and prevent unnecessary or ineffective care, but also concerns about optimizing people’s well-being. This can promote both objectives.” – Jack Stevens, MD

So far, most research has been done with adults, but Charlene Wong, MD, assistant professor of pediatrics and a health services/health policy researcher at Duke University, believes incentives that work in pediatric medicine may prove to be the most impactful.

“Disease starts before adulthood. If we’re able to help kids develop healthier habits or take better control of their chronic diseases, that would have implications for population health and costs for the health care system,” says Dr. Wong, whose practice focuses on adolescent health. “To prevent disease, even better.”

“We have a real opportunity to improve health for many, many years,” she says.

Unlike traditional economics, which assumes people always make decisions in their own best interest, behavioral economics assumes people frequently make biased decisions that are not always in their best interest. For example, many people opt for the immediate gratification of overeating and don’t consider the long-term damage of obesity.

Interventions – nudges – that address common decision errors can make it harder for people to make bad decisions and easier to make better choices, researchers say. A variety of strategies are showing promise.

For example, a common problem among patients is their failure to take medications consistently, even when they’re aware of the benefits. Typically, doctors suggest to patients that they set a daily reminder.

“Behavioral economics ups this by asking the patient to set the reminder before leaving the office,” Dr. Stevens says. Or, even stronger, the office will set it up and the doctor tells the patient to expect automatic reminders. In either case, the patient can disregard or discontinue the reminders.

Dr. Wong has completed a study using financial incentives to encourage adolescents with type 1 diabetes to check their glucose at least four times a day. “We were using the behavioral economics principle of loss aversion, which is that people are more motivated by losses than gains. Participants would lose money from a virtual account if they failed to monitor their glucose appropriately,” she says. “We found that daily loss aversion financial incentives got them to check their glucose more.”

Among providers, a study published in the Journal of the American Medical Association, used different nudges to reduce inappropriate prescriptions for antibiotics. Sometimes, “patients are miserable and expect or demand an antibiotic, and the doctor gives the prescription,” Dr. Stevens says.

But when a clinician entered the diagnostic code for a viral infection such as influenza in the electronic medical record and prescribed an antibiotic, the clinician immediately received a message saying the prescription may be inappropriate. The clinician was then asked to write a sentence or two to explain why this prescription was ordered. And, the clinician knew others may see the record. “These nudges decreased the likelihood that a clinician would prescribe an inappropriate antibiotic,” Dr. Stevens says.

Drs. Wong and Stevens say more research is needed to determine whether behavioral economics will work in pediatrics.

“Incentivizing parents for their children’s health or young people themselves is a different construct, both in the parent/child dyad and neurodevelopmentally, than designing these interventions for adults,” Dr. Wong says. “We’re also targeting behaviors like physical activity and healthy eating, which in many cases, have benefit much further down the road than reduced hospitalization. However, the pay-off is significant and multiplied by many more years of health.”

Most studies have been short-term and Drs. Stevens, Wong and some colleagues question whether the incentive effect of nudges diminishes over time. Nudges, may become ignored as patients or physicians become accustomed and tune them out, they say.

But if the incentive wears off, evidence of improved health may be enough to encourage a patient, parent or provider to continue down the path, Dr. Stevens says.

Another hurdle, according to Dr. Stevens, is that health care professionals may consider the strategies too unsophisticated to change behavior and dismiss them out of hand. “We don’t expect a panacea,” he says. “But if it’s low-cost and has a meaningful benefit, it’s worth doing.”

Both researchers warn that interventions won’t work on people who have no interest in changing. Learning to identify those who are willing or want to change will be critical to efficiently using strategies and resources. In all cases, Stevens says, the use of interventions must have a compelling and ethical rationale – such as to increase vaccination rates and to protect children.

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References:

  1. Stevens J. The promising contributions of behavioral economics to quality improvement in health care. Pediatric Quality and Safety. 2017 May/Jun;2(3): e023.
  2. Meeker D, Linder JA, Cox CR, Friedberg MW, Persell SD, Goldstein NJ, Knight TK, Hay JW, Doctor JN. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial. Journal of the American Medical Association. 2016 Feb 9;315(6): 562-570.

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