Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral...
Transcript of Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral...
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Using Nudges to Improve the
Delivery of Health Care
Mitesh Patel, MD, MBA, MS
February 2020
Director, Penn Medicine Nudge Unit;Ralph Muller Presidential Assistant Professor,
Perelman School of Medicine and The Wharton School, University of Pennsylvania;Staff Physician, Crescenz Veterans Affairs Medical Center, Philadelphia
Nudgeunit.upenn.edu @PennNudgeUnit
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Disclosures
• Research funding– NIH, VA, Donaghue Foundation, Doris Duke Charitable Foundation, Deloitte Consulting
• Advisory Board Member– Life.io, Healthmine Services, Holistic Industries
• Consulting– Catalyst Health
– www.miteshspatel.com
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Human behavior is the final common pathway
Patel, Volpp, Asch. NEJM. 2018
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Human behavior is the final common pathway
Patel, Volpp, Asch. NEJM. 2018
![Page 5: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/5.jpg)
Human behavior is the final common pathway
Patel, Volpp, Asch. NEJM. 2018
![Page 6: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/6.jpg)
Human behavior is the final common pathway
Patel, Volpp, Asch. NEJM. 2018
![Page 7: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/7.jpg)
Human behavior is the final common pathway
Patel, Volpp, Asch. NEJM. 2018
![Page 8: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/8.jpg)
Medical decision-making is often suboptimal
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Medical decision-making is often suboptimal
• Sometimes we do too much– Nearly one-third of health care spending is wasteful and unnecessary
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Medical decision-making is often suboptimal
• Sometimes we do too much– Nearly one-third of health care spending is wasteful and unnecessary
• Sometimes we don’t do enough– We often fail to practice evidence-based medicine
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Medical decision-making is often suboptimal
• Sometimes we do too much– Nearly one-third of health care spending is wasteful and unnecessary
• Sometimes we don’t do enough– We often fail to practice evidence-based medicine
90% of clinicians
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Medical decision-making is often suboptimal
• Sometimes we do too much– Nearly one-third of health care spending is wasteful and unnecessary
• Sometimes we don’t do enough– We often fail to practice evidence-based medicine
90% of clinicians 80% of US adults
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Using nudges to improve our decisions
• Subtle changes in design that can have an outsized impact on our behavior
• Remind, guide, or motivate decisions
Patel, Volpp, Asch. NEJM. 2018
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Using nudges to improve our decisions
• Subtle changes in design that can have an outsized impact on our behavior
• Remind, guide, or motivate decisions
• Examples– Setting the default to the preferred option
– Prompting an active choice now rather than delaying the decision
– Framing information through increased transparency or social comparisons
Patel, Volpp, Asch. NEJM. 2018
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Nudges are prevalent in other industries
Patel, Volpp, Asch. NEJM. 2018
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Nudges are prevalent in other industries
Patel, Volpp, Asch. NEJM. 2018
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Nudges are prevalent in other industries
Patel, Volpp, Asch. NEJM. 2018
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Nudges are prevalent in other industries
Patel, Volpp, Asch. NEJM. 2018
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Nudges are prevalent in other industries
Patel, Volpp, Asch. NEJM. 2018
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Nudge units are behavioral design teams
• Systematically test ways to improve decisions and change behavior
Patel, Volpp, Asch. NEJM. 2018
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Nudge units are behavioral design teams
• Systematically test ways to improve decisions and change behavior
• UK Behavioral Insights Team – Launched in 2010 by the United Kingdom’s Government
Patel, Volpp, Asch. NEJM. 2018
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Nudge units are behavioral design teams
• Systematically test ways to improve decisions and change behavior
• UK Behavioral Insights Team – Launched in 2010 by the United Kingdom’s Government
– Quickly demonstrated that small changes could lead to significant impact• Efficiency: tax payments
• Health: organ donor consent rates
• Social good: charitable contributions
Patel, Volpp, Asch. NEJM. 2018
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Nudge units have spread around the world within governments
OECD Research 2018
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Nudge units have spread around the world within governments
OECD Research 2018
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World’s first behavioral design team embedded in a health system
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World’s first behavioral design team embedded in a health system
Mission
To leverage insights from behavioral economics and psychology to design and test approaches to steer medical decision-making toward higher value and improved patient outcomes
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World’s first behavioral design team embedded in a health system
Mission
To leverage insights from behavioral economics and psychology to design and test approaches to steer medical decision-making toward higher value and improved patient outcomes
![Page 28: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/28.jpg)
Our role
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Impact
50+projects
12+
specialties
20+team
members
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Impact
50+projects
12+
specialties
Oncology
Cardiology
Pediatrics
Endocrine
Sleep Medicine
Internal Medicine
Family Medicine
Infectious Disease
Hospital Medicine
Radiation Oncology
Emergency Medicine
20+team
members
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Prioritizing opportunities
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Prioritizing opportunities
Right fit for a nudge
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Prioritizing opportunities
Right fit for a nudge
Leverages scalable technology
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Prioritizing opportunities
Right fit for a nudge
Leverages scalable technology
Potential for significant impact
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Prioritizing opportunities
Right fit for a nudge
Leverages scalable technology
Potential for significant impact
![Page 36: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/36.jpg)
Nudges vary in their approach and effectiveness
Patel, Navathe, Liao. JACR. 2019
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Nudges vary in their approach and effectiveness
Patel, Navathe, Liao. JACR. 2019
Effe
ctiv
en
ess
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Lessons from the Penn Medicine Nudge Unit
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We are already being nudged whether we know it or not
Patel et al. Ann Intern Med. 2014
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We are already being nudged whether we know it or not
Patel et al. Ann Intern Med. 2014
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We are already being nudged whether we know it or not
Patel et al. Ann Intern Med. 2014
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We are already being nudged whether we know it or not
Brand
Generic
Patel et al. Ann Intern Med. 2014
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Generic prescription rates: opt-in versus opt-out
Patel et al. JAMA IM. 2016
75.3% 98.4%
P<0.001
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Generic prescription rates: opt-in versus opt-out
Patel et al. JAMA IM. 2016
75.3% 98.4%
P<0.001
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Generic prescription rates: opt-in versus opt-out
Patel et al. JAMA IM. 2016
75.3% 98.4%
P<0.001
![Page 46: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/46.jpg)
Generic prescription rates: opt-in versus opt-out
Patel et al. JAMA IM. 2016
75.3% 98.4%
P<0.001
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Generic prescription rates: opt-in versus opt-out
Patel et al. JAMA IM. 2016
75.3% 98.4%
P<0.001
![Page 48: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/48.jpg)
Generic prescription rates: opt-in versus opt-out
Patel et al. JAMA IM. 2016
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Generic prescription rates: opt-in versus opt-out
Patel et al. JAMA IM. 2016
75.3% 98.4%
P<0.001
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Opioid addiction is linked to the size of the initial prescription
43%
Delgado et al. JGIM. 2018
P<0.001
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Opioid addiction is linked to the size of the initial prescription
43%
Delgado et al. JGIM. 2018
P<0.001
![Page 52: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/52.jpg)
Opioid addiction is linked to the size of the initial prescription
43%
Delgado et al. JGIM. 2018
P<0.001
![Page 53: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/53.jpg)
Opioid addiction is linked to the size of the initial prescription
43%
Delgado et al. JGIM. 2018
P<0.001
![Page 54: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/54.jpg)
Opioid addiction is linked to the size of the initial prescription
43%
Implemented Opioid Prescription Defaults in the ED
Delgado et al. JGIM. 2018
P<0.001
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Opioid addiction is linked to the size of the initial prescription
21%
43%
Implemented Opioid Prescription Defaults in the ED
Delgado et al. JGIM. 2018
P<0.001
![Page 56: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/56.jpg)
Opioid addiction is linked to the size of the initial prescription
21%
43%
Implemented Opioid Prescription Defaults in the ED
Delgado et al. JGIM. 2018
P<0.001
![Page 57: Using Nudges to Improve the Delivery of Health Care...2020/02/07 · Nudge units are behavioral design teams •Systematically test ways to improve decisions and change behavior •UK](https://reader034.fdocuments.net/reader034/viewer/2022050309/5f710683ec1811691a6f2990/html5/thumbnails/57.jpg)
Reducing Unnecessary Imaging
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Reducing Unnecessary Imaging
National guidelines recommend that palliative cancer patients do not have imaging to align radiation therapy
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Reducing Unnecessary Imaging
National guidelines recommend that palliative cancer patients do not have imaging to align radiation therapy
80% of these patients at Penn Medicine received daily imaging
(e.g. 14 CT scans for a 2-week course of radiation)
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Selecting a nudge intervention
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Selecting a nudge intervention
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Selecting a nudge intervention
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Selecting a nudge intervention
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Selecting a nudge intervention
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Imaging for Palliative Cancer Patients
Sharma et al. JAMA Oncology. 2019
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Imaging for Palliative Cancer Patients
Sharma et al. JAMA Oncology. 2019
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Imaging for Palliative Cancer Patients
Sharma et al. JAMA Oncology. 2019
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Imaging for Palliative Cancer Patients
Sharma et al. JAMA Oncology. 2019
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Imaging for Palliative Cancer Patients
Sharma et al. JAMA Oncology. 2019
68.2% 32.4%
P<0.01
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Imaging for Palliative Cancer Patients
Sharma et al. JAMA Oncology. 2019
68.2% 32.4%
P<0.01
3000 less imaging tests per year
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Complex Decision Pathways
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Cardiac rehab referral
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Cardiac rehab referral
• Evidence-based pathway– Demonstrated to reduce mortality and readmissions by up to 30%
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Cardiac rehab referral
• Evidence-based pathway– Demonstrated to reduce mortality and readmissions by up to 30%
• Referral rates are low– Only 15% of patients at Penn were referred at the time of hospital discharge
– More than 25% of hospitals in the US refer less than 20% of their patients
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Cardiac rehab referral
• Evidence-based pathway– Demonstrated to reduce mortality and readmissions by up to 30%
• Referral rates are low– Only 15% of patients at Penn were referred at the time of hospital discharge
– More than 25% of hospitals in the US refer less than 20% of their patients
• Manual opt-in process– Cardiologists had to complete paper form with 12+ fields while on rounds
– Patients had to identify a rehab center on their own and check insurance coverage
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Redesigned as an opt-out decision pathway
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Redesigned as an opt-out decision pathway
Automate identification and notification
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Redesigned as an opt-out decision pathway
Automate identification and notification
Restructure rounding and discharge process
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Cardiac Rehab Referral Rates Over Time
Adusumalli, Patel et al. Under Review
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Cardiac Rehab Referral Rates Over Time
Adusumalli, Patel et al. Under Review
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Cardiac Rehab Referral Rates Over Time
Adusumalli, Patel et al. Under Review
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Active Choice Framing
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Active choice to prompt decision-making
• Alternative to relying on the individual to make a decision
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Active choice to prompt decision-making
• Alternative to relying on the individual to make a decision
• Individual is stopped from proceeding unless they make a choice between options (Yes or No)
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Active choice to prompt decision-making
• Alternative to relying on the individual to make a decision
• Individual is stopped from proceeding unless they make a choice between options (Yes or No)
• Design– Prompt decision when you have the physician’s attention
– Increase saliency of advantages and disadvantages for each option
– Make it easy to say yes
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Active choice to prompt decision-making
• Alternative to relying on the individual to make a decision
• Individual is stopped from proceeding unless they make a choice between options (Yes or No)
• Design– Prompt decision when you have the physician’s attention
– Increase saliency of advantages and disadvantages for each option
– Make it easy to say yes
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Influenza vaccination rates
Patel et al. JGIM. 2017
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Influenza vaccination rates
Patel et al. JGIM. 2017
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Influenza vaccination rates
Patel et al. JGIM. 2017
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Influenza vaccination rates
• Active choice prompt targeted to physicians and medical assistants
Patel et al. JGIM. 2017
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Influenza vaccination rates
• Active choice prompt targeted to physicians and medical assistants
• Difference-in-difference analysis– 6.6 percentage point increase (P<.001)
– 37.3% relative increase in vaccination rates
Patel et al. JGIM. 2017
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Influenza vaccination rates
• Active choice prompt targeted to physicians and medical assistants
• Difference-in-difference analysis– 6.6 percentage point increase (P<.001)
– 37.3% relative increase in vaccination rates
• Expanded to other primary carepractices at Penn Medicine
Patel et al. JGIM. 2017
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Influenza vaccination rates
• Active choice prompt targeted to physicians and medical assistants
• Difference-in-difference analysis– 6.6 percentage point increase (P<.001)
– 37.3% relative increase in vaccination rates
• Expanded to other primary carepractices at Penn Medicine– Number of notifications reduced
Patel et al. JGIM. 2017
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Influenza vaccination rates
• Active choice prompt targeted to physicians and medical assistants
• Difference-in-difference analysis– 6.6 percentage point increase (P<.001)
– 37.3% relative increase in vaccination rates
• Expanded to other primary carepractices at Penn Medicine– Number of notifications reduced
– Redirected to medical assistants to template orders for physicians
Patel et al. JGIM. 2017
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Influenza vaccination rates after an active choice intervention
Kim, Patel et al. JAMA Network Open. 2018
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Influenza vaccination rates after an active choice intervention
Kim, Patel et al. JAMA Network Open. 2018
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Influenza vaccination rates after an active choice intervention
Compared to Control
Adjusted difference9.5 percentage points
95% CI: 4.1 – 14.3
P<0.001
Kim, Patel et al. JAMA Network Open. 2018
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Nudges for Population Health
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Nudges for Population Health
40,000 patients at Penn Medicine
meet national guidelines for statin therapy
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Nudges for Population Health
40,000 patients at Penn Medicine
meet national guidelines for statin therapy
Only about 50% have ever been prescribed a statin
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Study design
• Sample– 96 PCPs from 32 practice sites comprising 4774
patients eligible but never prescribed a statin
• Randomized, controlled trial– Usual care
– Active choice dashboard
– Active choice dashboard + peer comparison feedback delivered once by email
Patel et al. JAMA Network Open. 2018
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Study design
• Sample– 96 PCPs from 32 practice sites comprising 4774
patients eligible but never prescribed a statin
• Randomized, controlled trial– Usual care
– Active choice dashboard
– Active choice dashboard + peer comparison feedback delivered once by email– Below median: compared to the median
– Above median: compared to 90% percentile
– >90th percentile: recognized as top performer
Patel et al. JAMA Network Open. 2018
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Study design
• Sample– 96 PCPs from 32 practice sites comprising 4774
patients eligible but never prescribed a statin
• Randomized, controlled trial– Usual care
– Active choice dashboard
– Active choice dashboard + peer comparison feedback delivered once by email– Below median: compared to the median
– Above median: compared to 90% percentile
– >90th percentile: recognized as top performer
Fake Backend
• Data from clinical warehouse
• Study team sent email to PCP
• PCP uses secure website to submit orders
• Study team templates orders in EHR
• PCP logs into EHR and signs orders
• Prescription sent to pharmacy electronically
• Study team sends letter to patient
Patel et al. JAMA Network Open. 2018
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Description of health system initiative
Patel et al. JAMA Network Open. 2018
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Description of health system initiative
Patel et al. JAMA Network Open. 2018
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Description of health system initiative
Patel et al. JAMA Network Open. 2018
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Automated patient dashboard
Patel et al. JAMA Network Open. 2018
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Automated patient dashboard
Patel et al. JAMA Network Open. 2018
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Automated patient dashboard
Patel et al. JAMA Network Open. 2018
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Automated patient dashboard
Patel et al. JAMA Network Open. 2018
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Automated patient dashboard
Patel et al. JAMA Network Open. 2018
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Automated patient dashboard
Patel et al. JAMA Network Open. 2018
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Dashboard Utilization
Patel et al. JAMA Network Open. 2018
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Dashboard Utilization
Active Choice(N=32)
Active Choice w/Peer Comparisons (N=32)
Accessed Dashboard 16/32 (50.0%) 12/32 (37.5%)
Submitted Decisions 4/32 (12.5%) 8/32 (25.0%)
Signed Prescription Orders 2/32 (6.3%) 8/32 (25.0%)
Patel et al. JAMA Network Open. 2018
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Dashboard Utilization
Active Choice(N=32)
Active Choice w/Peer Comparisons (N=32)
Accessed Dashboard 16/32 (50.0%) 12/32 (37.5%)
Submitted Decisions 4/32 (12.5%) 8/32 (25.0%)
Signed Prescription Orders 2/32 (6.3%) 8/32 (25.0%)
Patel et al. JAMA Network Open. 2018
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Dashboard Utilization
Active Choice(N=32)
Active Choice w/Peer Comparisons (N=32)
Accessed Dashboard 16/32 (50.0%) 12/32 (37.5%)
Submitted Decisions 4/32 (12.5%) 8/32 (25.0%)
Signed Prescription Orders 2/32 (6.3%) 8/32 (25.0%)
Patel et al. JAMA Network Open. 2018
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Active Choice Dashboards to Increase Statin Prescribing
Patel et al. JAMA Network Open. 2018
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Active Choice Dashboards to Increase Statin Prescribing
Patel et al. JAMA Network Open. 2018
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Active Choice Dashboards to Increase Statin Prescribing
Patel et al. JAMA Network Open. 2018
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Active Choice Dashboards to Increase Statin Prescribing
Active choice and peer comparisons
5.8 percentage points
95% CI: 0.9 to 13.0
P<0.01
Patel et al. JAMA Network Open. 2018
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Growing interest in implementing nudge units in health care
Changolkar, Patel et al. NEJM Catalyst. 2019
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Summary: Nudging Medical Decision-Making
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Summary: Nudging Medical Decision-Making
• Medical decision-making is often suboptimal
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Summary: Nudging Medical Decision-Making
• Medical decision-making is often suboptimal
• Design of choice environments influences our behavior– We are already being nudged but are often unaware of it
– Strategic attention to align design with our goals
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Summary: Nudging Medical Decision-Making
• Medical decision-making is often suboptimal
• Design of choice environments influences our behavior– We are already being nudged but are often unaware of it
– Strategic attention to align design with our goals
• Nudge units can improve the delivery of health care– Systematic approach to design, implement, and test interventions
– Steer decisions towards higher value and better patient outcomes
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Using Nudges to Improve the
Delivery of Health Care
Nudgeunit.upenn.edu @PennNudgeUnit
Mitesh Patel, MD, MBAEmail: [email protected]
Twitter: @miteshspatel
Website: www.miteshspatel.com