Redesigning the 'choice architecture' of hospital prescription charts: a mixed methods study incorporating in situ simulation testing

Sharpening clinical decision support alert and reminder designs with MINDSPACE: A systematic review

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).

Applications of Behavioral Economics to Pharmaceutical Policymaking: A Scoping Review with Implications for Best-Value Biological Medicines

BACKGROUND AND OBJECTIVE

Pharmaceutical policies are generally based on the assumption that involved stakeholders make rational decisions. However, behavioral economics has taught us that this is not always the case as people deviate from rational behavior in rather predictable patterns. This scoping review examined to what extent behavioral concepts have already been applied in the pharmaceutical domain and what evidence exists about their effectiveness, with the aim of formulating future applications and research hypotheses on policymaking for best-value biologicals.

METHODS

A scoping literature review was conducted on the evidence of behavioral applications to pharmaceuticals. Scientific databases (Embase, MEDLINE, APA PsycArticles, and Scopus) were searched up to 20 October, 2021.

RESULTS

Forty-four full-text scientific articles were identified and narratively described in this article. Pharmaceutical domains where behavioral concepts have been investigated relate to influencing prescribing behavior, improving medication adherence, and increasing vaccination uptake. Multiple behavioral concepts were examined in the identified studies, such as social norms, defaults, framing, loss aversion, availability, and present bias. The effectiveness of the applied interventions was generally positive, but depended on the context. Some of the examined interventions can easily be translated into effective policy interventions for best-value biological medicines. However, some applications require further investigation in a research context.

CONCLUSIONS

Applications of behavioral economics to pharmaceutical policymaking are promising. However, further research is required to investigate the effect of behavioral applications on policy interventions for a more sustainable market environment for best-value biological medicines.

Reducing postoperative pain in children undergoing strabismus surgery: From bundle implementation to clinical decision support tools

BACKGROUND

Postoperative pain is a significant cause of morbidity in pediatric anesthesia, which can result in delayed discharge and unplanned hospital admission. Children undergoing strabismus surgery are known to be a particularly high-risk group for postoperative pain.

AIM

The aim of this project was to reduce the incidence of moderate to severe postoperative pain by 25% over a period of 12 months in children undergoing strabismus surgery.

METHODS

This was a multidisciplinary quality improvement project using the Institute for Healthcare Improvement model for improvement and iterative Plan-Do-Study-Act cycles. Baseline data from one hundred patients were collected retrospectively from patient records. Subsequently, iterative interventions introduced comprised: a perioperative bundle (comprising preoperative acetaminophen, intraoperative dexamethasone and ketorolac, a long-acting opioid, and two anti-emetics), email reminders, dissemination of results at departmental rounds, and an intraoperative clinical decision aide. Postoperative pain data were collected as an outcome measure, and length of stay in PACU was monitored as a balancing measure. Statistical process control charts were constructed to monitor bundle compliance and incidence of postoperative pain in the postanesthesia care unit.

RESULTS

Postoperative pain and bundle compliance data were collected for 1127 children in total. Baseline mean monthly incidence of moderate to severe postoperative pain was 47.3%. By the conclusion of this project, the incidence of postoperative pain decreased to 21%. Concurrently, mean bundle compliance increased to 78.7%. Mean length of PACU stay for baseline audit patients was 72.5 min compared with 70 min for patients after the introduction of the strabismus macro (November 2018-April 2019, n 91) (mean difference, 2.5; 95% CI, -3.86 to 8.86; P = .439).

CONCLUSION

Through the implementation and adoption of an evidence-based bundle of care, we successfully decreased the incidence of moderate to severe postoperative pain for children undergoing strabismus repair. We demonstrated that combining nudge theory with QI methodology can be an effective means of delivering positive results in quality improvement projects.

Architecting Process of Care: A randomized controlled study evaluating the impact of providing nonadherence information and pharmacist assistance to physicians

OBJECTIVE

To test the impact of connecting physicians, pharmacists, and patients to address medication nonadherence, and to compare different physician choice architectures.

DATA SOURCES AND STUDY SETTING

The study was conducted with 90 physicians and 2602 of their patients on medications treating chronic illness.

STUDY DESIGN

In this cluster randomized controlled trial, physicians were randomly assigned to an arm where the physician receives notification of patient nonadherence derived from real-time claims data, an arm where they receive this information and a pharmacist may contact patients either by default or by physician choice, and a control group. The primary outcome was resolving nonadherence within 30 days. We also considered physician engagement outcomes including viewing information about nonadherence and utilizing a pharmacist.

DATA COLLECTION

Physician engagement was constructed from metadata from the study website; adherence outcomes were constructed from medication claims.

PRINCIPAL FINDINGS

We see no differences between the treatment arms and control for the primary adherence outcome. The pharmacist intervention was 42 percentage points (95% CI: 28 pp-56 pp) more likely when it was triggered by default.

CONCLUSIONS

Access to a pharmacist and real-time nonadherence information did not improve patient adherence. Physician process of care was sensitive to choice architecture.

Successful use of "Choice Architecture" and "Nudge Theory" in a quality improvement initiative of analgesia administration after Caesarean section

BACKGROUND

Regular, routine, multimodal analgesia provides better pain relief following Caesarean section than reliance on "as required" opiate dosing. This quality improvement report describes the effective use of an education programme coupled with a highlighted, preprinted medication chart, employing "Nudge Theory" principles to achieve significant improvements in the administration of analgesic medications to patients after Caesarean section operations.

PROBLEM

An acute pain service audit identified a serious deficiency with delivery of regular postoperative analgesic medications to patients following Caesarean section operations.

METHODS

An audit of pain medication delivery to patients following Caesarean section demonstrated that postoperative analgesia was not being administered in line with local prescribing guidelines. Two interventions were planned: Education sessions for anaesthetic recovery and ward staff. Introduction of a new preprinted and highlighted medication chart. A postintervention audit was then conducted.

RESULTS

There were statistically significant improvements in all medications administered to patients following the two interventions. For analgesic medications, the rate of administration of drugs in compliance with guidelines rose from 39.6% to 89.9% (P < 0.001 using 2-sample z test). Each subgroup of medications also showed statistically significant improvements in administration compliance.

CONCLUSION

A combined approach, including application of "Nudge Theory" to the administration of analgesic medication after Caesarean section, considerably improved delivery of medications prescribed for postoperative analgesia.

A change in behaviour: getting the balance right for research and policy

Behaviour change interventions offer clinical pharmacists many opportunities to optimise the use of medicines. 'MINDSPACE' is a framework used by a Government-affiliated organisation in the United Kingdom to communicate an approach to changing behaviour through policy. The Theoretical Domains Framework (TDF) organises constructs of psychological theories that are most relevant to behaviour change into 14 domains. Both frameworks offer a way of identifying what drives a change in behaviour, providing a target for an intervention. This article aims to compare and contrast MINDSPACE and the TDF, and serves to inform pharmacy practitioners about the potential strengths and weaknesses of using either framework in a clinical pharmacy context. It appears that neither framework can deliver evidence-based interventions that can be developed and implemented with the pace demanded by policy and practice-based settings. A collaborative approach would ensure timely development of acceptable behaviour change interventions that are grounded in evidence.

Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project

Background

Prescribing errors occur in up to 15% of UK inpatient medication orders. However, junior doctors report insufficient feedback on errors. A barrier preventing feedback is that individual prescribers often cannot be clearly identified on prescribing documentation.

Aim

To reduce prescribing errors in a UK hospital by improving feedback on prescribing errors.

Interventions

We developed three linked interventions using plan–do–study–act cycles: (1) name stamps for junior doctors who were encouraged to stamp or write their name clearly when prescribing; (2) principles of effective feedback to support pharmacists to provide feedback to doctors on individual prescribing errors and (3) fortnightly prescribing advice emails that addressed a common and/or serious error.

Implementation and evaluation

Interventions were introduced at one hospital site in August 2013 with a second acting as control. Process measures included the percentage of inpatient medication orders for which junior doctors stated their name. Outcome measures were junior doctors' and pharmacists' perceptions of current feedback provision (evaluated using quantitative pre-questionnaires and post-questionnaires and qualitative focus groups) and the prevalence of erroneous medication orders written by junior doctors between August and December 2013.

Results

The percentage of medication orders for which junior doctors stated their name increased from about 10% to 50%. Questionnaire responses revealed a significant improvement in pharmacists' perceptions but no significant change for doctors. Focus group findings suggested increased doctor engagement with safe prescribing. Interrupted time series analysis showed no difference in weekly prescribing error rates between baseline and intervention periods, compared with the control site.

Conclusion

Findings suggest improved experiences around feedback. However, attempts to produce a measurable reduction in prescribing errors are likely to need a multifaceted approach of which feedback should form part.

The effectiveness of an enhanced invitation letter on uptake of National Health Service Health Checks in primary care: a pragmatic quasi-randomised controlled trial

BACKGROUND

The National Health Service Health Check (NHS HC) is a population level public health programme. It is a primary prevention initiative offering cardiovascular risk assessment and management for adults aged 40-74 years (every five years). It was designed to reduce the incidence of major vascular disease events by preventing or delaying the onset of diabetes, heart and kidney disease, stroke and vascular dementia . Effectiveness of the programme has been modelled on a national uptake of 75% however in 2012/13 uptake, nationally, was 49%. Ensuring a high percentage of those offered an NHS HC actually receive one is key to optimising the clinical and cost effectiveness of the programme.

METHODS

A pragmatic quasi-randomised controlled trial was conducted in four general practitioner practices in Medway, England with randomisation of 3511 patients. The aim was to compare attendance at the NHS HC using the standard national invitation template letter (control) compared to an enhanced invitation letter using insights from behavioural science (intervention). The intervention letter includes i) simplification - reducing letter content for less effortful processing ii) behavioural instruction - action focused language iii) personal salience - appointment due rather than invited and iv) addressing implementation intentions with a tear off slip to record the date, time and location of the appointment. Logistic Regression explored the association between control and intervention group and attendance at a health check.

RESULTS

29.3% of patients who received the control letter and 33.5% of those who received the intervention letter attended their NHS HC (adjusted odds ratio 1.26, 95% confidence interval 1.09-1.47, p < 0.01). This was an absolute difference in uptake of 4.2 percentage points for those receiving the intervention letter.

CONCLUSIONS

An invitation letter applying behavioural insights was more effective than the existing national template letter at encouraging attendance at an NHS HC. Making small, no cost behaviourally informed changes to letter invitations can improve uptake of the NHS HC. Further research is required to replicate the effect with more robust methodology and powered for sub-group analysis including socio-economic status.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66757664 , date of registration 28/3/2014.