Default options in healthcare

Pedro Rey

Although we talked extensively about the shared clinical decision between doctor and patient, many decisions made in health care are not chosen fully consciously. Among these "decisions", one powerful example is the power of default options: those established protocols that indicate what will be done if no other decision is actively made.

How to inform, persuade and remind about COVID-19 vaccination

Pedro Rey
 

@varelalaf

After a year in which the fight to control the transmission of COVID-19 has set the agenda, the debate is now focused on how to get a sufficient percentage of the population vaccinated to achieve the so-called "group immunity" as soon as possible. The objective now goes to the supply side: it is about establishing the sequence in which different population groups should be vaccinated (and with which vaccine each one) and making sure that the prioritization is fulfilled. We must also resolve as soon as possible how to eliminate bureaucratic obstacles so that vaccines are more easily accessible, more operational from a logistical point of view and can be purchased by the states at a reasonable price. However, solving the supply problem will be futile if we fail to stimulate demand so that the effective vaccination rate is as high as possible. For this, it is essential to understand both how the potential vaccination subjects behave ‒guided by their beliefs, their perceptions about safety and risk and by their cognitive biases‒ and in what way we can influence that behaviour to guide them towards the socially desirable direction that allows the reduction of disease incidence. 

Do financial incentives work to improve treatment adherence?

Pedro Rey
 

Laura Diego del Río & Pedro Rey

The effectiveness of a treatment depends as much on the prescriber's correct diagnosis and recommendations, as on whether the patient complies with the treatment guidelines that have been indicated. Lack of treatment adherence is one of the major problems related to medications, as it has a direct effect on both the effectiveness of the treatment and the healthcare costs. It’s estimated that in the group of patients with chronic diseases, adherence does not exceed 50%, with non-compliance being even higher in certain diseases, such as psychiatric diseases, in which it’s considered that only 25% of patients follow the treatment prescribed.

Should drugs cost "their worth"? What is the fair price?

Pedro Rey

 

There is a significant tension between the promise of medical innovation and affordable access to such innovation. The introduction of new drugs on the market at ever-increasing prices is perceived as the main inducer of the uncontrolled increase in healthcare spending in most developed countries, putting the viability of proper healthcare at risk and creating access barriers. This trend, which had been moderated in recent years by the exhaustion of the development of new products through chemical synthesis, has been reactivated with the new biotechnological products. In many countries, not only in less developed ones, the cost of treatment for diseases such as cancer can be unaffordable, either because it falls entirely on the patient or because the public system that finances it cannot afford it. Similarly, when a potential cure for hepatitis C became available recently, even high-income countries found themselves rationing treatment and looking for ways to guarantee access.

A Nobel Prize in Economics for health interventions that alleviate extreme poverty

Pedro Rey

The recent 2019 Nobel Prize in Economics has been awarded to three academic economists: Abhijit Banerjee and Esther Duflo of MIT and Michael Kremer of Harvard "for their experimental approach to alleviating world poverty." His research has revolutionized the way of studying how the economic development of the more than 700 million people living in extreme poverty can be stimulated. It enunciates the prioritization of small interventions in pilot tests and based on the knowledge of why those affected do not make optimal decisions that could contribute to their prosperity. It also forwards a more macro and institutional approach that depends on large programs that "should" work in theory, but in which the cause-effect relationship of its effectiveness has not been empirically established in all cases.

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.

Is my child hyperactive or is it simply that he is too small?

Pedro Rey

Parents are increasingly worried about their children being been diagnosed with attention deficit hyperactivity syndrome (ADHD). In fact, in the United States, the proportion of children between two and five years who were diagnosed with this syndrome increased by more than 50% from 2007 to 2012. It is estimated that in 2016 the worldwide prevalence of ADHD diagnosis in children under 18 years old was 5% and in the United States, for example, 5.2% of children of these ages take medication. Spain is one of the main consuming countries of methylphenidate, one of the medicines used to treat ADHD, whose consumption has multiplied by more than 30 in the last 15 years.

How to ensure that healthcare professionals read clinical practice guidelines?

Laura Diego Del Río & Pedro Rey 

During the last decades, there has been a dramatic increase in the clinical information available to healthcare professionals and best-practice reference documents have been established in different areas of medicine. An example of this is the numerous clinical practice guidelines developed by various institutions. Despite the vast amount of criticism bout their limitations; their elaboration implied a great effort to establish quality standards and a significant publication of literature on adoption strategies in clinical practice. However, given this abundance of information, there are certain doubts about whether they are being read and followed through. Let us analyze the main reasons and see what can be done to change this (lack of) practice, under the prism of behavioural economics.

Five Clinical Practice Lessons from the Nobel Prize in Economics

Pedro Rey

The 2017 Nobel Prize in Economics was awarded to Richard H. Thaler ,from the University of Chicago, for his contributions to behavioural economics. As I have explained before, this discipline combines the teachings of economics and psychology to better understand and predict human behaviour and to help us make better decisions, especially in areas such as health, where the combination of having to take many decisions involving risk and having to share private information with people with whom our incentives are not always perfectly aligned, makes us sensitive to multitude of emotions, failures of rationality and psychological biases.

Incentives to change unhealthy habits: Do they work? Are they ethical?

Pedro Rey

In a previous post I talked about the use of economic incentives to improve the quality of the prescription that physicians make. Today I want to focus on the other side of the problem, that of patients who try to self-stimulate or receive external incentives, to change their life habits towards healthier behaviour. There are two questions of interest for me: 1. Do incentives work? 2. Is it "ethical" to use "economic" incentives to induce changes towards healthier behaviours?

Health incentives: don’t shoot the behavioural economists!

Pedro Rey

The debate on the allocation of (economic) incentives associated with the performance of health professionals has been relevant for a long time. A few months ago, VOX has published an editorial with a very clear title: Paying Doctors Bonuses for Better Health Outcomes Makes Sense in Theory. But it doesn’t Work. The article cites numerous recent studies, such as this one on the United Kingdom or the United States, that show no effect of giving incentives to physicians either in their clinical practice patterns (inputs) or in health outcomes (outputs). A systematic review of studies on "pay for performance" (P4P) in the Annals of Internal Medicine reaches similar negative conclusions. However, a marked anti-economist tone of these articles emerges that I believe comes from a confusion. According to these articles, economists only know how to prescribe the use of incentives, without evaluating their effects, and also the incentives that we advise are only monetary and don’t appeal to the many different motivations, not only monetary, that can affect doctors decisions.

The paternalism of presenting the glass half full or half empty

Pedro Rey

In previous entries, both Cristina Roure and Jordi Varela have talked about how cognitive biases and, in particular, our difficulty in understanding what probabilistic calculations really mean, can affect important decisions about our health. Today I want to show you an example, originally due to psychologists Daniel Kahneman and Amos Tversky, about the importance of the way in which health information is presented in cases in which it is necessary to make a clinical decision, given that there is uncertainty and thus, there exist different possible options which may not offer certain results. In order to better understand the example here presented, I suggest that after reading the following paragraph, you stop for a second to think and decide, before moving on to read the paragraph that follows.

“Imagine that you are a health manager who must decide between two possible measures in the face of the outbreak of an epidemic that is expected to kill 600 people. The information you have about the consequences of the two measures you should choose is as follows: if you decide to take measure A, you know with certainty that 200 people will be saved. If you decide to take measure B there is a 1/3 chance that the 600 people will be saved (and therefore, a 2/3 chance that no one will be saved). Which of the two measures would you choose?”  Please take a moment to think about it and write it on a piece of paper before continuing reading.

Imagine now that, faced with the same epidemic, you must choose between these two other measures. If you choose measure C, 400 people will die. If you choose measure D, there is a 1/3 chance that no one will die (and a 2/3 chance that 600 people will die). Which of the two measures would you decide now?

Having read the two paragraphs, you have probably already realized that there exists contradiction: measures A and C are identical in their expected consequences, as are measures B and D. However, it’s likely that you, like 72% of the subjects of multiple experiments who are asked to decide between A and B, may have chosen A, while, like 78% of the subjects who are asked to choose between C and D, you may have chosen D in the second question. How can this inversion of preferences occur?

Kahneman and Tversky, based in evidence from simple experiments like the one I have shown you, are responsible for the so-called "prospective theory", which offers an explanation. Summarizing it briefly, the theory says that human beings suffer more from negative events than what they enjoy from positive events, which leads us to behave as risk-averse when dealing with positive outcomes, and instead behaving like risk-lovers when faced with events which may have negative consequences. When we must choose between A and B many of us value more the certainty of saving 200 lives with measure A than taking the risk inherent to measure B, which with a low probability will save even more people. However, when it comes to assuming deaths, i.e., when choosing between C and D, we feel better when taking measure D (equivalent to B), which with low probability can achieve not deaths, than when taking measure C (equivalent to A) which assures us that we’ll have to take responsibility for the death of 200 people.

The problem presented by this example is not so much that it demonstrates that human beings are contradictory, which barely surprises us anymore, but that it opens the door for us to be manipulated when making decisions, merely by how the data is presented to us. This manipulation capacity is of particular importance in clinical practice where, for example, in an environment in which an attempt is made to promote shared decision making between doctor and patient about which treatment to follow, the doctor can continue to exercise full control over the patient through presenting the information of the healing possibilities or possible side effects in a positive or negative way. Therefore, it’s important to recognize that, if you really want to favor freedom of choice in situations that by definition involve risks, and thus probabilities, it’s necessary either to move towards greater education of those who receive the information so that they are able to interpret it correctly being aware of their own cognitive biases, or to do an enormous exercise of honesty and exposing this type of mind tricks, dedicating enough time to helping others  understand in an objective way, and not biased by our own self-interest, the expected consequences of their decisions, in some cases literally of life or death;  Give me freedom of choice or paternalism based on the specialists’ expertise but don’t disguise one as the other.