NudginginHealth

WhyNudgeinHealth?

•  Healthcareisthemostexpensive,mostcomplexanduniversalpolicysectorwithlifeanddeathimplica<onsforeveryci<zen– Everytradi<onalmeanshasbeentried

•  Decisionmakingishighlycomplex–highlevelofvaria<onandriskineachcase

•  Doctors,alliedhealthprofessionalsandpa<entsallresistanttodirec<veapproach

Anearlycaseofnudginginhealth•  Thetoothbrush–  invented7thcentury;–  importedtoEuropesome<meaGer13thcentury–  Commonusagebegins20thcentury

•  Thenudginginnova<on–toothpasteanditspsychologicalunderpinnings:–  Foam,thoughnon-func<onal,providesfeedback– Mintyfreshness,thoughitdoesn’tlast,indicatedsuccessfulcomple<on

–  Filmremoval,thoughinsignificanttooralhealth,makesteethfeelcleanandhealthy.

Casestudy:Appropriateness •  Appropriatenessistheproperorcorrectuseofhealthservices,productsandresources.

•  Inappropriatecarecaninvolveoveruse,underuseand/ormisuseofhealthservices,productsandresources

SomeAppropriatenessData

•  Asmuchas30%ofhealthcareinCanadaisunnecessary

•  Radia<onfromafullbodyCTscan=200,000airportscans;mammogram=4,000scans

•  Halfofan<bio<cprescrip<onsareunnecessaryandcontributetoresistantstrains.

•  70%ofdiagnosescanbedeterminedonthebasisofmedicalhistoryalone–notests.

Moreappropriatenessdata

Service Condi4on(s) No.ofStudies RangeofOveruseRates,%(2000–2009)

Coronaryangiography MI,CAD 17 8.0–21.8

Coronaryrevasculariza<on CAD 16 1.4–14.0

Upperendoscopy Bleeding(upper),PUD 7 19.0–23.0

Radiographsinacuterespiratoryillnesses

Bronchioli<s,asthma 5 32.0–72.0

Colonoscopy ColonCA 4 23.0–60.8

An<bio<cs URI,acutebronchi<s 59 2.0–89.0

Bronchodilators Obstruc<vediseases 6 30.0–81.0

KorensteinD,etal.OveruseofhealthcareservicesintheUnitedStates:anunderstudiedproblem.ArchInternMed.2012;172:171-8

AppropriatenessExamples

•  Electrocardiograms(ECGs)•  BackPainImaging(X-Ray;CT;MRI)•  CTScansandMRIsforheadaches•  Bone-densityTests•  An<bio<csforsinusi<s

WhyDoesOveruseHappen?

•  Physicianhabit•  Pa<entdemand•  Physicianlackofknowledge•  Fearofli<ga<on•  Financialincen<ves•  Specialistrequirementsforreferrals•  “MoreorNewisBejer”fallacy•  Timepressures

“ChoosingWisely”Ini<a<ve•  Reduce10MillionUnnecessaryTestsandTreatmentsby2020

•  Reduc<onisaboutoveruse,wasteandharm–notcostsavings(thoughcostsavingswillhappen).

•  Whynudge?–adirec<veapproachdangerous;shouldn’ttellpa<entsnottoaskfortestsortreatments

•  Approach–s<mulatethinkingandpa<ent-physicianconversa<on.–  Pa<entfacingmaterial–  Physicianfacingmaterial–  “5ThingsPhysiciansandPa<entsShouldQues<on”lists

Resultsandfurtherapproaches•  Furtherapproaches:– Benchmarking– Pa<entOrderSets

Impact of Blind Spot Monitor Prescriptions of Benzodiazepines to Elderly Patients

*Comparison periods 7/13/13 to 8/6/13 and 8/7/13 to 8/31/13

Change in number of prescriptions from baseline with active alert* Age >=65 years Age <65 years

Pilot MD offices -20.9% 3.6% Control MD offices 10.6% 3.5% Difference -31.5% +0.01%

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Otherexamplesofnudginginhealthcare•  Pricingofhospitalsupplies•  OrganDona<on(Opt-invsOptout)•  TheFakeBusStopandDemen<aPa<ents•  Nudgingalsohaspoten<alforwellness– Prolifera<onofFitnessTrackers– GroceryCartModifica<ons– Architecturetopromotewellnessatwork(parking,staircases,etc.)

Someconcerns

•  Ethics– Whatdoyouwantyourphysicianthinkingabout?– Who,bydefault,hasrightstoyourorgans?– Arewemanipula<ngpeople?

•  Unintendedconsequences– Howhardarewebeingnudged?