The Use of Nudge Strategies in Improving Physicians' Prescribing Behavior: A Systematic Review and Meta-analysis.

BACKGROUND: Nudges have been proposed as a method of influencing prescribing decisions. PURPOSE: The purpose of this article is to 1) investigate associations between nudges' characteristics and effectiveness, 2) assess the quality of the literature, 3) assess cost-effectiveness, and 4) create a synthesis with policy recommendations. METHODS: We searched health and social science databases. We included studies that targeted prescribing decisions, included a nudge, and used prescribing behavior as the outcome. We recorded study characteristics, effect size of the primary outcomes, and information on cost-effectiveness. We performed a meta-analysis on the standardized mean difference of the studies' primary outcomes, tested for associations between effect size and key intervention characteristics, and created a funnel plot evaluating publication bias. SYNTHESIS: We identified 21 studies containing 25 nudges. In total, 62 of 85 (73%) outcomes showed a statistically significant effect. The average effect size was -0.22 standardized mean difference. No studies included heterogeneity analyses. We found no associations between effects and selected study characteristics. Study quality varied and correlated with study design. A total of 7 of 21 (33%) studies included an evaluation of costs. These studies suggested that the interventions were cost-effective but considered only direct effects. We found evidence of publication bias. LIMITATIONS: Heterogeneity and few studies limit the possibilities of statistical inference about effectiveness. CONCLUSIONS: Nudges may be effective at directing prescribing decisions, but effects are small and health effects and cost-effectiveness are unclear. Future nudge studies should contain a rationale for the chosen nudge, prioritize the use of high-quality study designs, and include evaluations of heterogeneity, cost-effectiveness, and health outcomes to inform decision makers. Moreover, preregistration of the protocol is warranted to limit publication bias. HIGHLIGHTS: Nudging as a method to improve prescribing decisions has gained popularity during the past decade.We find that nudging can improve prescribing decisions, but effect sizes are mostly small, and the size of derived health outcomes is unclear.Most studies use feedback and error-stopping nudges to target excessive opioid or antibiotic prescribing, making heterogeneity analyses across nudge types difficult.Further research on the cost-effectiveness of nudges and generalizability is needed to guide decision makers considering nudging as a tool to guide prescribing decisions.

Nudging to assist opioid tapering among chronic non-malignant pain patients: A systematic scoping review.

Objectives: Use of opioids can lead to frequent and severe side effects, prompting the exploration of non-pharmacological alternatives, including nudging, to reduce opioid consumption. This review identifies and evaluates patient-targeted nudges to support opioid tapering among adults with chronic non-cancer pain. Methods: We searched EMBASE, MEDLINE, CINAHL, PsycInfo, and Social Science citation index for articles published from 2010 to January 2023. Eligibility criteria were based on the PICOS framework and included original peer-reviewed English language studies on adults with chronic non-cancer pain and interventions aligning with the nudge definition by Thaler and Sunstein. Studies with relevant comparators, measurable outcomes, real-world data, and pre/post-intervention measures were included. Data were manually extracted and reported in a descriptive manner. The process adhered to PRISMA-ScR reporting guidelines. Results: Four of 222 articles fulfilled the inclusion criteria. All included nudges aimed at providing information to support decision-making and behavior change. Three nudge categories were identified: increasing salience, understanding mappings, and feedback. Outcome measures were program-related, focusing on perceptions, knowledge acquisition, engagement metrics, and psychological well-being. Conclusions: There were no statistically significant effects or only small evidence of effects in the program-related outcomes. None of the studies included a control group with standard care or no intervention comparison and none included objective measures of opioid reduction. More studies are needed to draw conclusions on the effectiveness of nudges to support opioid tapering among chronic non-cancer pain patients.

A colonized general practice? A critical habermasian analysis of how general practitioners experience defensive medicine in their everyday working life.

The aim of this article is to show how Jürgen Habermas' communicative action theory serves as a useful tool in analysing and interpreting empirical data on how Danish general practitioners experience defensive medicine in their everyday working life. Through six qualitative focus group interviews with a total of 28 general practitioners (14 men and 14 women), the general practitioners' understandings of and experiences with defensive medicine were unfolded and discussed. Traditionally, defensive medicine is understood as physicians' deviation from sound medical practice due to fears of liability claims or lawsuits. In this study, however, a broader understanding of defensive medicine emerged as unnecessary medical actions that are more substantiated by feelings of demands and pressures than meaningful clinical behaviour. As a first analytical step, the data are contextualized drawing on the medical sociological literature that has theorized recent changes within primary health care such as regulation, audit, standardization and consumerism. Using Habermas' theorization to further interpret the general practitioners' experiences, we argue that central areas of the general practitioners' clinical everyday work life can be seen as having become subject to the habermasian social and political processes of 'strategic action' and 'colonization'. It is furthermore shown that the general practitioners share an impulse to resist these colonizing processes, hereby pointing to a need for challenging the increasingly defensive medical culture that seems to pervade the organization of general practice today.

Designing Unforced Choice Experiments to Inform Health Care Decision Making: Implications of Using Opt-Out, Neither, or Status Quo Alternatives in Discrete Choice Experiments.

Background. Discrete choice experiments (DCEs) are increasingly used in the health care context to inform on patient preferences for health care services. In order for such experiments to provide useful and policy-relevant information, it is vital that the design includes those options that the respondent faces in the real-life situation. Whether to include opt-out, neither, or status quo alternatives has, however, received little attention in the DCE literature. We aim to investigate whether the use of different unforced choice formats affects DCE results in different settings: 1) opt-out versus neither in a health care market where there is no status quo and 2) including status quo in addition to opt-out in a health care market with a status quo. Design. A DCE on Dutch citizens' preferences for personal health records served as our case, and 3189 respondents were allocated to the different unforced choice formats. We used mixed logit error component models to estimate preferences. Results. We found that the use of different unforced choice formats affects marginal utilities and welfare estimates and hence the conclusions that will be drawn from the DCE to inform health care decision making. Conclusions. To avoid biased estimates, we recommend that researchers are hesitant to use the neither option and consider including a status quo in addition to opt-out in settings where a status quo exists.

[Preferences for user fees in general practice and the establishment of general practitioners in rural areas]. / Praeferencer for brugerbetaling i almen praksis og nedsaettelse i yderkantsområder.

This study elicits the preferences of general practitioners (GPs) and patients for different ways of mitigating problems with a general and structural lack of GPs in Denmark. The supply of GPs can be increased in rural areas if the GPs are compensated (approximately 470,000 DKK per year in extra surplus) and if other non-pecuniary factors are implemented. The study further showed that there was a positive willingness to pay for a consultation (74-85 DKK), although the majority of the GPs do not support this initiative.