Reducing Overprescription with Psychology based Interventions

Pedro Rey

There exits consensus about drug overprescription having become a significant public health problem, both for its health effects and for its budgetary repercussions. The case of the opioid "epidemic" in the United States frequently comes under scrutiny. We must not forget the abuse of benzodiazepines (especially) during hospital treatment or the loss of efficacy of antibiotics due to the development and selection of bacteria that developed resistance due to improper and excessive use. Traditional methods of combating these problems have been to try to educate both the medical profession and patients, to train prescribers or to review prescribing practices and create automated alert systems. However, although in some cases these measures have been relatively successful in the short term, they have also been shown to be not cost-effective, to lose efficacy in the medium term, and to be challenging to transfer to significant interventions.

Behavioural science aims to understand the personal reasons behind the individual who exercises or suffers from over-prescription to offer cheap, effective and scalable solutions. A psychological study feeds this type of measures by analyzing prescribers' motivations (and to a certain extent also of the patients' motives). To do this, it redesigns incentive mechanisms that promote one type or another of behaviour and also uses small psychological tricks (nudges) that, without entering into conscious changes in the motivations of the individuals can substantially modify unconscious behaviour. Although my research area focuses more on the design of incentives that appeal to psychological motivations, today I want to talk about, due to its current relevance and notoriety, the second type of measures: nudges.

Nudges as an instrument of change

The main idea behind a nudge is that not all of our decisions are conscious and look for the best option. In other words, our actions do not always reflect what we think is best for ourselves or others, but much of our decisions use shortcuts, intuitions or general rules (rules of thumb) that simplify them. Although this system is very efficient, it is prone to systematic errors: cognitive biases. Fortunately, these primary and not necessarily conscious decision rules are easily replaceable by others that radically alter behaviour.

Let us give some examples. Sometimes our decisions are based on simple comparisons with reference groups, such as colleagues by profession, who influence and matter to us more than we are willing to admit. At other times, the reference is what is customary to do, the default option, so we do not even consider modifying our behaviour unless we need to conform to a new default option. At other times, we get carried away by routines, and so we do not spend on evaluating alternatives. Finally, other times we simply ignore the consequences of our actions, either due to ignorance or misinformation.

This type of behaviour, relatively automatic, can potentially be modified with small, low-cost interventions. If the prescribers are fundamentally guided by the behaviour of their reference group, inform them that they are overprescribing when compared with other doctors who treat similar pathologies. This may lead them to prescribe less because of the new information and the implicit threat that they are deviating from the norm. In case the default option is not appropriate, changing it can be relatively easy. For example, the considerable differences in organ donation rates between some countries seem to be explained by the fact that in those countries where few organs are donated, the administrative procedure to declare yourself a donor actively is crucial, while in other countries the default option is that citizens are donors unless they actively claim not wanting to be.

Similarly, when alternative drugs are ignored, information about drugs with similar effects may make them more aware of other possibilities without affecting the practitioner's freedom of choice. Other more coercive measures, such as forcing the prescriber to justify why he prescribes a particular drug, may also make him consider other possibilities. Also, if the problem is ignoring the consequences of prescribing behaviour, an automatic warning system can be introduced. The system would contain precise and relevant data on, for example, the issue of antibiotic resistance, the cost of indiscriminate use of a specific drug for the health system, the possible consequences for the prescriber of having abnormal behaviour or, even, the provision of shocking data on health outcomes.

A nudge must contain relevant and surprising information.

The key for these measures to be practical is that they introduce a reference change, that is, that the information they contain is new and surprising enough for the physician to take it into account. A habit hardly changes with old news. Therefore it is crucial to understand which of the different types of behaviour (comparisons, routines, ignorance ) is the one that can be affected with the most significant impact. However, w could use a combined approach that provides all the information at the same time on behaviour other than that of reference groups, that offers alternatives and reports on the consequences of certain practices.

A recent NEJM Catalyst article compares the relative effectiveness of different types of interventions for various pathologies and drugs. One of the main messages is that there is not necessarily a type of intervention that works in all contexts or for all prescribers.

The reluctance to reduce drug prescription may be due to conditions of the pathology or the treatment itself and individual attitudes of the doctors. For this reason, the central message of my entry is that we are not only open to allow small psychological interventions that can work, but also rigorous evaluation of the same. Experiments on small programs that check the relative efficacy of different small-scale interventions before being led, again, by an automatic rule may have us believe that what has worked in one specific study works in another.

As health experts accustomed to clinical trials, we should be more open to trial and error to make decisions based on evidence. Eliminate bureaucratic obstacles, making it easier and cheaper to carry out experiments informed by psychology on the behaviour of doctors and patients, and at the same time share the results in a systematic way so that we all learn from these experiences. It is undoubtedly a winning strategy.