It’s alarming to read headlines regarding deaths caused by overdoses. The misuse of opioids – including prescription pain killers, heroin and other artificial opioids have become a severe national crisis affecting public health. Beyond public health, opioid addiction also affects social and economic welfare. According to the Centers for Disease control and Prevention, “In the United States, the total economic burden of prescription opioid misuse alone is $78.5 billion a year, which includes the costs of healthcare, lost productivity, addiction treatment and criminal justice involvement.”
Healthcare experts, including researchers and implementation scientists, are working to combat the deadly toll that this epidemic is wreaking on society. One of the ways to tackle this problem can be through a simple “nudge” technique. According to Richard Thaler and Cass Sunstein (2008), “Nudge is a concept in behavioral sciences that describes an intervention that ‘alters people’s behavior predictably without forbidding any options or significantly changing their economic incentives” (pg. 6). If a heavy object is nudged by just one person’s index finger, it might not move. However, if enough people nudged together, real change might be created. The same goes for population health and the opioid crisis.
In recent years, interest in practice improvement through nudges has grown due to the transparent, inexpensive and effective influences they have on behaviors towards specific program/practice goals. A research study published in JAMA Surgery (2018) is a perfect example. The authors observed that by lowering the default number of prescription pills from 30 to 12 in a multi-hospital electronic medical record system, there was a significant decrease of opioid prescribed after ten standard outpatient surgical procedures without an increase in analgesic refill rates that would indicate inadequately treated pain. The authors described this strategy in their study as a “simple, effective, cheap, and potentially wide-reaching intervention that can be harnessed to help change the culture of opioid overprescribing among providers.” The study demonstrated that a nudge could be useful in changing prescribing behavior in health care.
In yet another study published in the Journal of American College of Surgeons (2018), researchers showed the spillover effect of making a change. When doctors changed their postoperative prescribing for one procedure, those habits trickled down into their prescribing behavior for other unrelated processes. Once doctors changed their practices to safer ones, the path of least resistance became the new, more reliable approaches. They are now familiar processes instead of new and unknown. The main hurdle to overcome was the first change, which required a nudge.
A study led by ER physician Kit Delgado at the University of Pennsylvania found a simple way to nudge emergency department doctors in the right direction by setting the electronic medical records system to default to the recommended 10 opioid pills to treat acute pain. In this experiment with the electronic medical record system, weekly prescribing patterns were compared for 22 weeks before and after the default number was changed. To choose a different quantity, doctors had to opt out of the default and click a different option or manually enter the number. An unintended positive outcome was a decrease in the proportions of doctors prescribing fewer pills, which fell from 20 percent to 15 percent. The Philadelphia Inquirer quoted Dr. Delgado, “This default-setting approach has expanded to 50 hospital emergency departments as part of an opioids study called Reduce. The three year project also gives individual prescribing reports to physicians so they can assess their patterns. If they realize they’re not meeting a performance target, it’s very motivating to change behavior.”
Researchers are making continued efforts in testing “nudges” to improve healthcare, such as using prompts in electronic medical records and using text messaging to boost prescribing of lower-cost generic drugs. Hence, nudges can be designed to remind, guide or motivate behavior. The Center for Health Innovation and Implementation Science at the Indiana University School of Medicine can provide the necessary tools on changing human behavior. Through education and engagement services, healthcare professionals can learn a proven, evidence-based change methodology that has been designed specifically to improve healthcare: Agile Implementation. To learn more, visit: https://hii.iu.edu/
Citations
Chiu AS, Jean RA, Hoag JR, Freedman-Weiss M, Healy JM, Pei KY (July 2018). Association of lowering default pill counts in electronic medical record systems with postoperative opioid prescribing. JAMA Surg. doi:10.1001/jamasurg.2018.2083
Florence CS, Zhou C, Luo F, Xu L (2013). The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States. Med Care. 2016; 54(10):901-906. doi:10.1097/MLR.0000000000000625.
McCullough, M. (2018). As addiction crisis grows, Penn’ nudges’ doctors to limit opioid prescriptions. The Philadelphia Inquirer. Retrieved from https://www.inquirer.com/philly/health/addiction/as-addiction-crisis-grows-penn-nudges-doctors-to-limit-opioid-prescriptions-20180118.html
Thaler RH, Sunstein CR. (2008). Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Pre
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