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Cain J, Behal M, Richter LM. An Integrative Scoping Review of Behavioral Economics Applications in Higher Education: Opportunities for Academic Pharmacy. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2024; 88:100732. [PMID: 38852679 DOI: 10.1016/j.ajpe.2024.100732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/28/2024] [Accepted: 06/01/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVES This integrative scoping review explores the applications of behavioral economics within higher education, particularly, through the lens of nudging (a concept that leverages insights from economics and psychology to guide individuals' decisions subtly). The primary objective is to provide a broad overview of interventions that use behavioral economics principles and, secondarily, discuss their potential to improve pharmacy education and create a foundation for future research in this area. FINDINGS The review analyzed 89 studies that applied behavioral economics principles in higher education settings. Reminders and prompts were the most frequently used principles, with generally positive outcomes, especially in enrollment management. Framing, incentives, and salience also demonstrated effectiveness, depending on the context. Social norms and simplification showed mixed results, whereas priming, loss aversion, feedback, comparison, and commitment had varying degrees of success in influencing behavior. SUMMARY Behavioral economics principles offer valuable insights and tools for enhancing various aspects of education. The review highlights the potential for using these principles to improve student engagement, enrollment processes, and health and well-being initiatives. However, it emphasizes the importance of context-specific design and careful implementation when applying these interventions. Future research opportunities exist to further explore the applications of behavioral economics in pharmacy education and beyond.
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Affiliation(s)
- Jeff Cain
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice & Science, Lexington, KY, USA.
| | - Michael Behal
- University of Tennessee Medical Center, Department of Pharmacy, Knoxville, TN, USA
| | - Lisa M Richter
- North Dakota State University College of Health and Human Sciences, Department of Pharmacy Practice, Fargo, ND, USA
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Soames J, Pettigrew LM. Electronic health record-based behaviour change interventions aimed at general practitioners in the UK: a mixed methods systematic review using behaviour change theory. BMJ Open 2024; 14:e080546. [PMID: 38816046 PMCID: PMC11141199 DOI: 10.1136/bmjopen-2023-080546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/24/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES Electronic health record (EHR) systems are used extensively in healthcare; their design can influence clinicians' behaviour. We conducted a systematic review of EHR-based interventions aimed at changing the clinical practice of general practitioners in the UK, assessed their effectiveness and applied behaviour change theory to identify lessons for other settings. DESIGN Mixed methods systematic review. DATA SOURCES MEDLINE, EMBASE, CENTRAL and APA PsycINFO were searched up to March 2023. ELIGIBILITY CRITERIA Quantitative and qualitative findings from randomised controlled trials (RCTs) controlled before-and-after studies and interrupted time series of EHR-based interventions in UK general practice were included. DATA EXTRACTION AND SYNTHESIS Quantitative synthesis was based on Cochrane's Synthesis without Meta-analysis. Interventions were categorised using the Behaviour Change Wheel and MINDSPACE frameworks and effectiveness determined by vote-counting using direction of effect. Inductive thematic synthesis was used for qualitative studies. RESULTS Database searching identified 3824 unique articles; 10 were included (from 2002 to 2021), comprising eight RCTs and two associated qualitative studies. Four of seven quantitative studies showed a positive effect on clinician behaviour and three on patient-level outcomes. Behaviour change techniques that may trigger emotions and required less cognitive engagement appeared to have positive effects. Qualitative findings indicated that interventions reassured clinicians of their decisions but were sometimes ignored. CONCLUSION Despite widespread use, there is little high quality, up-to-date experimental evidence evaluating the effectiveness of EHR-based interventions in UK general practice. The evidence suggested EHR-based interventions may be effective at changing behaviour. Persistent, simple action-oriented prompts appeared more effective than complex interventions requiring greater cognitive engagement. However, studies lacked detail in intervention design and theory behind design choices. Future research should seek to optimise EHR-based behaviour change intervention design and delineate limitations, providing theory-based justification for interventions. This will be of increasing importance with the growing use of EHRs to influence clinicians' decisions. PROSPERO REGISTRATION NUMBER CRD42022341009.
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Affiliation(s)
- Jamie Soames
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Luisa M Pettigrew
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Garzón-Orjuela N, Vornhagen H, Blake C, Vellinga A. Evaluation of different landing pages on behavioural engagement with the CARA dashboard: A user research protocol. BMC PRIMARY CARE 2024; 25:174. [PMID: 38769539 PMCID: PMC11103958 DOI: 10.1186/s12875-024-02420-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND CARA set out to develop a data-visualisation platform to facilitate general practitioners to develop a deeper understanding of their patient population, disease management and prescribing through dashboards. To support the continued use and sustainability of the CARA dashboards, dashboard performance and user engagement have to be optimised. User research places people at the centre of the design process and aims to evaluate the needs, behaviours and attitudes of users to inform the design, development and impact of a product. OBJECTIVE To explore how different initial key messages impact the level of behavioural engagement with a CARA dashboard. METHODS Participating general practices can upload their practice data for analysis and visualisation in CARA dashboards. Practices will be randomised to one of three different initial landing pages: the full dashboard or one of two key messages: a between comparison (their practice prescribing with the average of all other practices) or within comparison (with practice data of the same month the previous year) with subsequent continuation to the full dashboard. Analysis will determine which of the three landing pages encourages user interaction, as measured by the number of 'clicks', 'viewings' and 'sessions'. Dashboard usage data will be collected through Google analytics. DISCUSSION This study will provide evidence of behavioural engagement and its metrics during the implementation of the CARA dashboards to optimise and sustain interaction. TRIAL REGISTRATION ISRCTN32783644 (Registration date: 02/01/2024).
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Affiliation(s)
- Nathaly Garzón-Orjuela
- CARA Network, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.
| | - Heike Vornhagen
- Insight Centre for Data Analytics, University of Galway, Galway, Ireland
| | - Catherine Blake
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Akke Vellinga
- CARA Network, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
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Cloyd CP, Macedone D, Merandi J, Pierson S, Sellas Wcislo M, Lutmer J, MacDonald J, Ayad O, Kalata L, Thompson RZ. A Quality Initiative to Improve Appropriate Medication Dosing in Pediatric Patients with Obesity. Pediatr Qual Saf 2024; 9:e741. [PMID: 38868757 PMCID: PMC11167219 DOI: 10.1097/pq9.0000000000000741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/17/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year. Methods The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department. Results Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months. Conclusions Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.
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Affiliation(s)
- Colleen P. Cloyd
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Danielle Macedone
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Nationwide Children’s Hospital Center for Clinical Excellence, Columbus, Ohio
| | - Jenna Merandi
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Shawn Pierson
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Maria Sellas Wcislo
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - Jeffrey Lutmer
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Jennifer MacDonald
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Onsy Ayad
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Lindsay Kalata
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
| | - R. Zachary Thompson
- From the Department of Pharmacy, Nationwide Children’s Hospital, Columbus Ohio
- Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
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Nuckols TK, Chen PG, Shetty KD, Brara HS, Anand N, Qureshi N, Skaggs DL, Doctor JN, Pevnick JM, Mannion AF. Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons. PLoS One 2024; 19:e0300475. [PMID: 38640131 PMCID: PMC11029649 DOI: 10.1371/journal.pone.0300475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/20/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. METHODS The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). RESULTS Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). CONCLUSIONS Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.
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Affiliation(s)
- Teryl K. Nuckols
- RAND Corporation, Santa Monica, CA, United States of America
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Peggy G. Chen
- RAND Corporation, Santa Monica, CA, United States of America
| | | | - Harsimran S. Brara
- Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States of America
| | - Neel Anand
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Nabeel Qureshi
- RAND Corporation, Santa Monica, CA, United States of America
| | - David L. Skaggs
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, Los Angeles, CA, United States of America
| | - Joshua M. Pevnick
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Hashemi S, Bai L, Gao S, Burstein F, Renzenbrink K. Sharpening clinical decision support alert and reminder designs with MINDSPACE: A systematic review. Int J Med Inform 2024; 181:105276. [PMID: 37948981 DOI: 10.1016/j.ijmedinf.2023.105276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/07/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Clinical decision support (CDS) alerts and reminders aim to influence clinical decisions, yet they are often designed without considering human decision-making behaviour. While this behaviour is comprehensively described by behavioural economics (BE), the sheer volume of BE literature poses a challenge to designers when identifying behavioural effects with utility to alert and reminder designs. This study tackles this challenge by focusing on the MINDSPACE framework for behaviour change, which collates nine behavioural effects that profoundly influence human decision-making behaviour: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitment, and Ego. METHOD A systematic review searching MEDLINE, Embase, PsycINFO, and CINAHL Plus to explore (i) the usage of MINDSPACE effects in alert and reminder designs and (ii) the efficacy of those alerts and reminders in influencing clinical decisions. The search queries comprised ten Boolean searches, with nine focusing on the MINDSPACE effects and one focusing on the term mindspace. RESULTS 50 studies were selected from 1791 peer-reviewed journal articles in English from 1970 to 2022. Except for ego, eight of nine MINDSPACE effects were utilised to design alerts and reminders, with defaults and norms utilised the most in alerts and reminders, respectively. Overall, alerts and reminders informed by MINDSPACE effects showed an average 71% success rate in influencing clinical decisions (alerts 73%, reminders 69%). Most studies utilised a single effect in their design, with higher efficacy for alerts (64%) than reminders (41%). Others utilised multiple effects, showing higher efficacy for reminders (28%) than alerts (9%). CONCLUSION This review presents sufficient evidence demonstrating the MINDSPACE framework's merits for designing CDS alerts and reminders with human decision-making considerations. The framework can adequately address challenges in identifying behavioural effects pertinent to the effective design of CDS alerts and reminders. The review also identified opportunities for future research into other relevant effects (e.g., framing).
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Affiliation(s)
- Sarang Hashemi
- Department of Human-Centred Computing, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia.
| | - Lu Bai
- Department of Human-Centred Computing, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Shijia Gao
- Department of Human-Centred Computing, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Frada Burstein
- Department of Human-Centred Computing, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
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Chew KS, Ooi SK, Abdul Rahim NF, Wong SSL, Kandasamy V, Teo SS. Perception of nudge interventions to mitigate medication errors risk in healthcare service delivery. BMC Health Serv Res 2023; 23:1310. [PMID: 38012617 PMCID: PMC10683206 DOI: 10.1186/s12913-023-10247-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Conventional cognitive interventions to reduce medication errors have been found to be less effective as behavioural change does not always follow intention change. Nudge interventions, which subtly steer one's choices, have recently been introduced. METHODS Conducted from February to May 2023, this study aimed to determine the relationships between perceived effectiveness and perceived ease of implementation of six nudge interventions to reduce medication errors, i.e., provider champion, provider's commitment, peer comparison, provider education, patient education and departmental feedback, and the moderating effects of seniority of job positions and clinical experience on nudge acceptability. Partial Least Square Structural Equation Modelling was used for data analysis. RESULTS AND DISCUSSION All six nudge strategies had significant positive relationships between perceived effectiveness and acceptability. In three out of six interventions, perceived ease of implementation was shown to have positive relationships with perceived acceptability. Only seniority of job position had a significant moderating effect on perceived ease of implementation in peer comparison intervention. Interventions that personally involve senior doctors appeared to have higher predictive accuracy than those that do not, indicating that high power-distance culture influence intervention acceptability. CONCLUSION For successful nudge implementations, both intrinsic properties of the interventions and the broader sociocultural context is necessary.
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Affiliation(s)
- Keng Sheng Chew
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, 94300, Sarawak, Malaysia.
| | - Say Keat Ooi
- Graduate School of Business, Universiti Sains Malaysia, 11800 USM, Pulau Pinang, Malaysia
| | | | - Shirly Siew-Ling Wong
- Faculty of Economics and Business, Universiti Malaysia Sarawak, Kota Samarahan, 94300, Sarawak, Malaysia
| | - Vanitha Kandasamy
- Sarawak General Hospital, Jalan Hospital, Kuching, 93586, Sarawak, Malaysia
| | - Shin-Shin Teo
- Sibu Hospital, KM 5 ½, Jalan Ulu Oya, Sibu, 96000, Sarawak, Malaysia
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Pezzolato M, Marzorati C, Lanzoni L, Monzani D, Masiero MA, Pietrobon R, Pravettoni G. "Interventions to increase adherence to oral therapies in breast cancer patients: A systematic review based on the behavior change technique taxonomy". Psychooncology 2023; 32:1481-1502. [PMID: 37571974 DOI: 10.1002/pon.6203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 06/29/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE High rates of non-adherence to oral medications in breast cancer (BC) patients have been reported. Here we provide an up-to-date systematic review of the interventions aimed at increasing adherence to oral medication in BC patients, with a particular focus on the content of the interventions. METHODS PubMed, Scopus, Embase and Ovid databases and reference lists of relevant studies were searched through October 2022. Studies which (1) described an intervention aimed at increasing adherence to oral anticancer medication, (2) included (or planned to include) at least one sub-group of BC patients, (3) were written in English, and (4) with full-text available were included. The contents of the interventions were coded using the Behavior Change Technique Taxonomy. Quality assessment was conducted using Downs and Black scale. RESULTS Thirty-six studies met the inclusion criteria and involved a total sample of 28,528 BC patients. Interventions were mainly delivered with eHealth devices (n = 21) and most of them used mobile app. Other studies used in-person modalities (e.g., CBT, relaxation technique) or written materials (e.g., psycho-educational booklet). The behavior change techniques most frequently implemented were "problem solving," "social support," "information about health consequences," and "prompts/cues". Quality assessment revealed that the higher risk of bias refers to the selection process. CONCLUSIONS The use of reminders, monitoring patients' medication-taking behaviors and giving feedback were the most frequently implemented techniques in those interventions that resulted significant. If these preliminary observations were to be confirmed by future comparative studies, they should be taken into account when developing new interventions.
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Affiliation(s)
- Massimo Pezzolato
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Chiara Marzorati
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Lucilla Lanzoni
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Dario Monzani
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
| | - Marianna Agnese Masiero
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Gabriella Pravettoni
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
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Khanal S, Schmidtke KA, Talat U, Turner AM, Vlaev I. Using multi-criteria decision analysis to describe stakeholder preferences for new quality improvement initiatives that could optimise prescribing in England. FRONTIERS IN HEALTH SERVICES 2023; 3:1155523. [PMID: 37409178 PMCID: PMC10318338 DOI: 10.3389/frhs.2023.1155523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/26/2023] [Indexed: 07/07/2023]
Abstract
Background Hospital decision-makers have limited resources to implement quality improvement projects. To decide which interventions to take forward, trade-offs must be considered that inevitably turn on stakeholder preferences. The multi-criteria decision analysis (MCDA) approach could make this decision process more transparent. Method An MCDA was conducted to rank-order four types of interventions that could optimise medication use in England's National Healthcare System (NHS) hospitals, including Computerised Interface, Built Environment, Written Communication, and Face-to-Face Interactions. Initially, a core group of quality improvers (N = 10) was convened to determine criteria that could influence which interventions are taken forward according to the Consolidated Framework for Implementation Research. Next, to determine preference weightings, a preference survey was conducted with a diverse group of quality improvers (N = 356) according to the Potentially All Pairwise Ranking of All Possible Alternatives method. Then, rank orders of four intervention types were calculated according to models with criteria unweighted and weighted according to participant preferences using an additive function. Uncertainty was estimated by probabilistic sensitivity analysis using 1,000 Monte Carlo Simulation iterations. Results The most important criteria influencing what interventions were preferred was whether they addressed "patient needs" (17.6%)' and their financial "cost (11.5%)". The interventions' total scores (unweighted score out of 30 | weighted out of 100%) were: Computerised Interface (25 | 83.8%), Built Environment (24 | 79.6%), Written Communication (22 | 71.6%), and Face-to-Face (22 | 67.8%). The probabilistic sensitivity analysis revealed that the Computerised Interface would be the most preferred intervention over various degrees of uncertainty. Conclusions An MCDA was conducted to rank order intervention types that stand to increase medication optimisation across hospitals in England. The top-ranked intervention type was the Computerised Interface. This finding does not imply Computerised Interface interventions are the most effective interventions but suggests that successfully implementing lower-ranked interventions may require more conversations that acknowledge stakeholder concerns.
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Affiliation(s)
- Saval Khanal
- Behavioural Science Group, Warwick Business School, University of Warwick, Coventry, United Kingdom
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Kelly Ann Schmidtke
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Liberal Arts, University of Health Sciences and Pharmacy, St Louis, MO, United States
| | - Usman Talat
- Alliance Manchester Business School, University of Manchester, Manchester, United Kingdom
| | - Alice M. Turner
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ivo Vlaev
- Behavioural Science Group, Warwick Business School, University of Warwick, Coventry, United Kingdom
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Tuckerman J, Harper K, Sullivan TR, Cuthbert AR, Fereday J, Couper J, Smith N, Tai A, Kelly A, Couper R, Friswell M, Flood L, Blyth CC, Danchin M, Marshall HS. Short Message Service Reminder Nudge for Parents and Influenza Vaccination Uptake in Children and Adolescents With Special Risk Medical Conditions: The Flutext-4U Randomized Clinical Trial. JAMA Pediatr 2023; 177:337-344. [PMID: 36806893 PMCID: PMC9941970 DOI: 10.1001/jamapediatrics.2022.6145] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/07/2022] [Indexed: 02/22/2023]
Abstract
Importance Children with chronic medical conditions are at increased risk of severe influenza. Uptake of influenza vaccination in children and adolescents with these identified special risk medical conditions (SRMCs) is suboptimal. Objective To assess the effectiveness of Flutext-4U, a parent short message service (SMS) reminder nudge intervention, in increasing influenza immunization in children and adolescents with SRMCs. Design, Setting, and Participants This randomized clinical trial was conducted at a tertiary pediatric hospital in Adelaide, South Australia, from April 15 to September 30, 2021. Children and adolescents aged 6 months to younger than 18 years with SRMCs and a subspecialist outpatient appointment over a 5-month period during the Australian seasonal influenza vaccination season (April-August 2021) were eligible to participate. Follow-up was until September 30, 2021. Interventions Participants were randomly assigned (1:1 ratio) to control: clinician nudges (hospital vaccine availability, ease of access, and recommendation from hospital subspecialists) or SMS intervention (control conditions plus an additional SMS reminder nudge to parents), with randomization stratified by age group (<5 years, 5-14 years, or >14 to <18 years). Main Outcomes and Measures The primary outcome was influenza vaccination, as confirmed by the Australian Immunisation Register. Results A total of 600 participants (intervention group: 298 [49.7%]; mean [SD] age, 11.5 [4.6] years; 162 female participants [54.4%]; control group: 302 [50.3%]; mean [SD] age, 11.4 [4.7] years; 155 female participants [51.3%]) were included. Influenza vaccination was 38.6% (113 of 293) in the SMS intervention group compared with 26.2% (79 of 302) in the control group (adjusted odds ratio [aOR], 1.79; 95% CI, 1.27-2.55; P = .001). Time to vaccine receipt was significantly lower among SMS participants (adjusted hazard ratio, 1.67; 95% CI, 1.25-2.22; P < .001). For participants randomly assigned by June 15, a significantly greater proportion receiving the SMS intervention were vaccinated during the optimal delivery period April to June 30 (SMS group: 40.0% [76 of 190] vs 25.4% [50 of 197]; aOR, 1.97; 95% CI, 1.28-3.06; P = .002). Conclusions and Relevance Results of this randomized clinical trial suggest that an additional SMS reminder nudge for parents delivered in the tertiary care hospital setting to children and adolescents with SMRCs resulted in higher influenza vaccine uptake compared with clinician nudges alone. Trial Registration ANZCTR Identifier: ACTRN12621000463875.
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Affiliation(s)
- Jane Tuckerman
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Vaccine Uptake Group, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Kelly Harper
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas R. Sullivan
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Alana R. Cuthbert
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Jennifer Fereday
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
| | - Jennifer Couper
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Nicholas Smith
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
| | - Andrew Tai
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Kelly
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
| | - Richard Couper
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
| | - Mark Friswell
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
| | - Louise Flood
- Communicable Disease Control Branch, South Australian Department of Health and Wellbeing, Adelaide, South Australia, Australia
| | - Christopher C. Blyth
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Department of Microbiology, PathWest Laboratory Medicine WA, Perth, Western Australia, Australia
| | - Margie Danchin
- Vaccine Uptake Group, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Department of General Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Helen S. Marshall
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Women's and Children’s Health Network, North Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
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11
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Woods-Hill CZ, Nelson MN, Eriksen W, Rendle KA, Beidas RS, Bonafide CP, Brajcich MR, Milstone AM, Shea JA. Determinants of Blood Culture Use in Critically Ill Children: A Multicenter Qualitative Study. Pediatr Qual Saf 2023; 8:e647. [PMID: 37051407 PMCID: PMC10085482 DOI: 10.1097/pq9.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/11/2023] [Indexed: 04/14/2023] Open
Abstract
Blood cultures are fundamental in diagnosing and treating sepsis in the pediatric intensive care unit (PICU), but practices vary widely. Overuse can lead to false positive results and unnecessary antibiotics. Specific factors underlying decisions about blood culture use and overuse are unknown. Therefore, we aimed to identify perceived determinants of blood culture use in the PICU. Methods We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics. Results We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts. Conclusions Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia Pa
| | - Maria N. Nelson
- University of Pennsylvania Mixed Methods Research Laboratory
| | | | | | | | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle R. Brajcich
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Judy A. Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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12
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Nurchis MC, Di Pumpo M, Perilli A, Greco G, Damiani G. Nudging Interventions on Alcohol and Tobacco Consumption in Adults: A Scoping Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1675. [PMID: 36767077 PMCID: PMC9913966 DOI: 10.3390/ijerph20031675] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 06/18/2023]
Abstract
Background: The World Health Organization identified alcohol and tobacco consumption as the risk factors with a greater attributable burden and number of deaths related to non-communicable diseases. A promising technique aimed to modify behavioral risk factors by redesigning the elements influencing the choice of people is nudging. Methodology: A scoping review of the literature was performed to map the literature evidence investigating the use of nudging for tobacco and alcohol consumption prevention and/or control in adults. Results: A total of 20 studies were included. The identified nudging categories were increasing salience of information or incentives (IS), default choices (DF), and providing feedback (PF). Almost three-quarters of the studies implementing IS and half of those implementing PF reported a success. Three-quarters of the studies using IS in conjunction with other interventions reported a success whereas more than half of the those with IS alone reported a success. The PF strategy performed better in multi-component interventions targeting alcohol consumption. Only one DF mono-component study addressing alcohol consumption reported a success. Conclusions: To achieve a higher impact, nudging should be integrated into comprehensive prevention policy frameworks, with dedicated education sessions for health professionals. In conclusion, nudge strategies for tobacco and alcohol consumption prevention in adults show promising results. Further research is needed to investigate the use of nudge strategies in socio-economically diverse groups and in young populations.
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Affiliation(s)
- Mario Cesare Nurchis
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | | | - Alessio Perilli
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Greco
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gianfranco Damiani
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
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13
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Wolf A, Sant'Anna A, Vilhelmsson A. Using nudges to promote clinical decision making of healthcare professionals: A scoping review. Prev Med 2022; 164:107320. [PMID: 36283484 DOI: 10.1016/j.ypmed.2022.107320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/25/2022] [Accepted: 10/18/2022] [Indexed: 10/31/2022]
Abstract
Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.
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Affiliation(s)
- Axel Wolf
- University of Gothenburg, Centre for Person-Centred Care (GPCC), Sweden; University of Gothenburg, Institute of Health and Care Sciences, Sahlgrenska Academy, Sweden
| | | | - Andreas Vilhelmsson
- Lund University, Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Sweden.
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14
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Khanal S, Schmidtke KA, Talat U, Sarwar A, Vlaev I. Implementation and Evaluation of Two Nudges in a Hospital’s Electronic Prescribing System to Optimise Cost-Effective Prescribing. Healthcare (Basel) 2022; 10:healthcare10071233. [PMID: 35885760 PMCID: PMC9316495 DOI: 10.3390/healthcare10071233] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 11/24/2022] Open
Abstract
Providing healthcare workers with cost information about the medications they prescribe can influence their decisions. The current study aimed to analyse the impact of two nudges that presented cost information to prescribers through a hospital’s electronic prescribing system. The nudges were co-created by the research team: four behavioural scientists and the lead hospital pharmacist. The nudges were rolled out sequentially. The first nudge provided simple cost information (percentage cost-difference between two brands of mesalazine: Asacol® and Octasa®). The second nudge provided information about the potential annual cost savings if the cheaper medication were selected across the National Health Service. Neither nudge influenced prescribing. Prescribing of Asacol® and Octasa® at baseline and during the implementation of the first nudge did not differ (at p ≥ 0.05), nor was there a difference between the first nudge and second (at p ≥ 0.05). Although these nudges were not effective, notable administrative barriers were overcome, which may inform future research. For example, although for legal reasons the cost of medicine cannot be displayed, we were able to present aggregated cost information to the prescribers. Future research could reveal more behavioural factors that facilitate medication optimisation.
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Affiliation(s)
- Saval Khanal
- Warwick Business School, University of Warwick, Scarman Road, Coventry CV4 7AL, UK
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK;
- Correspondence: (S.K.); (I.V.)
| | - Kelly Ann Schmidtke
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK;
- Behavioral Science, University of Health Science and Pharmacy, St. Louis, MO 63110, USA
| | - Usman Talat
- Alliance Manchester Business School, University of Manchester, Manchester M13 9PL, UK;
| | - Asif Sarwar
- Pharmacy Department, Queen Elizabeth II Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK;
| | - Ivo Vlaev
- Warwick Business School, University of Warwick, Scarman Road, Coventry CV4 7AL, UK
- Correspondence: (S.K.); (I.V.)
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