“Nudging” patients towards better adherence to improve outcomes

• “Nudging” increases the likelihood of a given behavior by invoking a patient’s System 1 decision making process.
• Nudging techniques are increasingly used by governments to shape healthcare and other public policies.
• Nudging techniques can also be used to enhance treatment adherence in clinical practice.

As described in previous articles, adherence to treatment for patients suffering from chronic pain, a close proxy to patients with vertigo, is a significant issue.¹ Low adherence comes with big costs for the patients, their families, and society as whole. The behavioral sciences help us understand the decision-making processes that lead to non-adherence, but how can healthcare professionals use these insights to help patients make better choices?

People can be “nudged” to make better health choices

Previous articles in this series describe the two systems of human decision making identified by prominent behavioral researchers Daniel Kahneman and Amos Tversky: (1) the automatic and spontaneous processes of System 1  and (2) the reflective, lazy processes of  System 2² ( << Two systems of thought: why “rational” people make “irrational” choices >>). System 1 is responsible for about 95% of all the choices that people make in their everyday lives.³ System 1 reactions are based on rules of thumb or heuristics rather than a full understanding of the situation followed by a careful assessment of risks and benefits. As a result, System 1 thinking is often prone to previously discussed biases such as framing, anchoring, and status quo bias. 

In their 2008 book Nudge, Nobel prize winner Richard Thaler and Holberg prize winner Cass Sunstein further developed their theory of decision making and made the case for what they call libertarian paternalism.⁴ They argue that most people are not experts in the many domains that affect their day-to-day life, and, when confronted with a choice, cannot spontaneously make the best decisions. For example, when offered a large number of health insurance policies, how does a novice in the market decide which one best fits his/her needs?* 

It is possible to help people optimize their decision making by presenting options in a manner that makes the best options more likely to be chosen, in other words to “nudge” System 1’s spontaneity into making the best choice. Given the primacy of System 1 heuristics in decision making, the value of being able to influence it in the area of health and disease management is clear. 

Nudging orients the individual’s choices to encourage the optimal decision 

Nudging techniques are not meant to eliminate choice. If a person wants to reflect on a decision rationally and employ the System 2 thinking, he/she can always override their System 1 processes. As Thaler and Sunstein explain, choice can be presented in such a way that patients still have absolute freedom to decide among the options, but the most beneficial choices become more likely for those who choose to rely on System 1.

Consider decisions surrounding human organ donation. Having human organs readily available at hospitals can save countless lives, yet, organ donation remains a difficult issue to address in many societies, making organ availability scarce. In Austria, the government solved this problem by applying the following nudge technique: The default option for Austrians is to donate organs automatically should the criteria for donation be satisfied. Austrians are always able to opt out of this program, but as a result of this nudge, 99% of Austrians consent to organ donation. By comparison, neighboring Germany has not employed this default consent to donation, and the rate of organ donation is only 12%.⁵  In other words, Austria has an opt-out program while Germany has an opt-in. Recognizing the utility of System 1 default bias has helped Austrians substantially increase the availability of organs and save lives. Opt-in/opt-out nudging techniques are increasingly used by authorities to shape public policy. 

Nudge approaches are used to enroll workers in pension schemes and healthcare plans, and even to decrease mortality rate on dangerous highways. Several countries, including the UK, USA, and Germany, have even created nudge units within their governments.

Enhancing adherence with nudging techniques 

A study of patients with chronic diseases was conducted by a group of UK and USA researchers in collaboration with the NHS.⁶ The aim of this study was to access the patient’s availability bias that they could more easily comprehend the benefits of medication adherence. The results of that study demonstrated that nudging patients with a reminder of the personal and societal costs of non-adherence is a very efficient means of improving adherence.

When is nudging needed?

According to Thaler and Sunstein, there are several situations in which nudges are particularly useful.⁷

• Benefits now, costs later: When an individual does not seriously consider the future consequences of their behavior, e.g. a smoker who does not seriously weigh the potential health problems that cigarettes cause, or someone who looks at the current benefit of eating ice cream (pleasure) without looking at the long term benefits of diet and exercise. According to Kahneman’s “What You See Is All There Is” principle,⁸ most people are unable to fully appreciate the future benefits of today’s efforts. Another example would be the patient suffering from vertigo (for example due to Meniere’s disease) who also happens to be a smoker with an unhealthy diet. Smoking or poor diet can have a negative impact on future vertigo events, although likely not immediately. Therefore, a nudge could be used to promote “healthy” decisions.
• Degree of difficulty: The more difficult the problem, the greater assistance is needed to make the right decision. A patient who is about to start a very complex treatment regimen with which he/she has no experience is likely to have low adherence⁹ if no help (nudge) is provided.
• Frequency: Imagine a patient that must give his/her consent for a surgery or treatment with uncertain outcomes but that is highly likely to improve their situation. Where a person is confronted with rare and difficult high-stakes decisions, a nudge stressing the likelihood of a positive outcome (e.g. a 90% success rate) can reduce the patient’s fears and help him/her make best decisions.
• Feedback: Sometimes people need feedback on the choices they’ve already made to make further decisions. For example, when a pupil is not doing his homework properly, the feedback in the form of a bad mark from the teacher is rapid, providing motivation for the pupil to improve on the next assignment. However, if the feedback on a poor decision is not readily available, a nudge may be appropriate to bridge the delay. Consider a person suffering from Meniere’s disease who has episodic vertigo events, but between those, has no symptoms: without any feedback available (symptoms or health events), the patient may not to adhere to his treatment plan.  
• Knowing what you want (and need): It is particularly hard for people to make choices when they cannot translate them into potential experiences. Thaler and Sunstein illustrate this by analogizing it to ordering food in a restaurant in a foreign language where a person may not have enough information to know what he/she wants, or may lack the skills to communicate what he/she needs. Nudges can direct a patient facing a multitude of treatment options that have different cost/benefit outcomes to the option that, in the provider’s best medical opinion, is most likely to yield the best outcome. 

Conclusions and perspectives

Nudging techniques represent a major opportunity for addressing non-adherence. Whatever the environment or culture, people have the same heuristics and two-systems process, so nudging techniques can be broadly adapted and applied. Healthcare professionals who employ the behavioral measurement tools discussed in the article, << Activating patients to improve adherence >>, and who use the previously discussed frameworks such as the Behavior Change Wheel to understand each patient’s behavioral drivers, can couple their insight with nudge techniques to positively and efficiently influence patients into making good decisions. The emergence of digital technologies and artificial intelligence make it increasingly possible to personalize nudge techniques to each person to improve outcomes for the patient, their family, and society in general. It is, however, important to note that the information on nudge techniques presented here cannot replace an actual and informed therapeutic approach. Future articles in this series will discuss how digital Patient Support Programs personalize nudge approaches and provide examples of how such techniques can improve adherence.

References

1. L. Timmerman et al. (2016). “Prevalence and determinants of medication non‐adherence in chronic pain patients: a systematic review,” ACTA Anesthesiologica Scandanvica, (60):4, pp. 416–431. https://doi.10.1111/aas.12697
2. Richard Thaler & Cass Sunstein (2008). Nudge, Part I, “Humans and econs,” Chapter 1, “Biases and blunders,” “How we think: Two systems.” (Please note that in Nudge, the authors refer to System 1 as the “automatic system” and to System 2 as the “reflective system.”)
3. Philip Iordanov (2018). “Thinking fast? Slow down,” Neurofied. 26 December, 2018. https://neurofied.com/thinking-fast-slow-down/
4. Richard Thaler & Cass Sunstein (2008). Nudge, Part I, “Humans and econs,” Chapter 1, “Biases and blunders,” “How we think: Two systems.”
5. Anand Damani (2015). “Why 99% of Austrians donate their organs,” Behavioural Design,11 August, 2015. http://www.behaviouraldesign.com/2015/08/11/why-99-of-austrians-donate-their-organs/#sthash.1ESiwL2p.dpbsc
6. Jon M. Jachimowicz (2019). “Making medications stick: Improving medication adherence by highlighting the personal health costs of non-compliance,” Behavioural Public Policy, pp. 1–21. https://doi:10.1017/bpp.2019.1 
7. Richard Thaler & Cass Sunstein (2008). Nudge, Part I, “When do we need nudge?” and “Fraught choices.”
8. Daniel Kahneman (2011). Thinking Fast and Slow, “Machine for jumping to conclusions, Section: What you see is all there is.”
9. Noemia Urruth Leão Tavares et al. (2016). “Factors associated with low adherence to medicine treatment for chronic diseases in Brazil,” Rev Saude Publica, (50) Supp. 2. https://doi: 10.1590/S1518-8787.2016050006150