Details matter: predicting when nudging clinicians will succeed or fail

Fox, Craig R.; Doctor, Jason N.; Goldstein, Noah J.; Meeker, Daniella; Persell, Stephen D.; Linder, Jeffrey A.

doi:10.1136/bmj.m3256

Cited by 36 publications

(38 citation statements)

References 30 publications

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“…109 , 110 However, as we have written previously, subtle differences between details of interventions matter. 111 In the example above, the commitment study by Meeker et al 99 was effective, but the commitment study by Kullgren et al 107 , 108 was not, perhaps because the commitment was not public and the follow-up duration was short.…”

Section: Details Mattermentioning

confidence: 98%

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

Richards

Linder

2021

Clinical Therapeutics

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Section: Details Mattermentioning

confidence: 98%

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

Richards

Linder

2021

Clinical Therapeutics

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“…We provided clinics with the same level of support during ACCEPt-able as during ACCEPt, but we did not monitor whether there were changes in the clinics’ use of other strategies to facilitate testing such as using computer alerts, and while new GPs received our chlamydia educational package, we did not provide any further educational support to already-participating GPs. The lack of ongoing ‘calibration’ of the intervention and its support may have contributed to declining testing rates across all groups [ 38 ]. In addition, our intervention targeted GPs, with negligible patient involvement, which is necessary for sustaining change over time [ 39 ].…”

Section: Discussionmentioning

confidence: 99%

The impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice: A cluster randomised controlled trial (ACCEPt-able)

et al. 2022

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Background Financial incentives and audit/feedback are widely used in primary care to influence clinician behaviour and increase quality of care. While observational data suggest a decline in quality when these interventions are stopped, their removal has not been evaluated in a randomised controlled trial (RCT), to our knowledge. This trial aimed to determine whether chlamydia testing in general practice is sustained when financial incentives and/or audit/feedback are removed. Methods and findings We undertook a 2 × 2 factorial cluster RCT in 60 general practices in 4 Australian states targeting 49,525 patients aged 16–29 years for annual chlamydia testing. Clinics were recruited between July 2014 and September 2015 and were followed for up to 2 years or until 31 December 2016. Clinics were eligible if they were in the intervention group of a previous cluster RCT where general practitioners (GPs) received financial incentives (AU$5–AU$8) for each chlamydia test and quarterly audit/feedback reports of their chlamydia testing rates. Clinics were randomised into 1 of 4 groups: incentives removed but audit/feedback retained (group A), audit/feedback removed but incentives retained (group B), both removed (group C), or both retained (group D). The primary outcome was the annual chlamydia testing rate among 16- to 29-year-old patients, where the numerator was the number who had at least 1 chlamydia test within 12 months and the denominator was the number who had at least 1 consultation during the same 12 months. We undertook a factorial analysis in which we investigated the effects of removal versus retention of incentives (groups A + C versus groups B + D) and the effects of removal versus retention of audit/feedback (group B + C versus groups A + D) separately. Of 60 clinics, 59 were randomised and 55 (91.7%) provided data (group A: 15 clinics, 11,196 patients; group B: 14, 11,944; group C: 13, 11,566; group D: 13, 14,819). Annual testing decreased from 20.2% to 11.7% (difference −8.8%; 95% CI −10.5% to −7.0%) in clinics with incentives removed and decreased from 20.6% to 14.3% (difference −7.1%; 95% CI −9.6% to −4.7%) where incentives were retained. The adjusted absolute difference in treatment effect was −0.9% (95% CI −3.5% to 1.7%; p = 0.2267). Annual testing decreased from 21.0% to 11.6% (difference −9.5%; 95% CI −11.7% to −7.4%) in clinics where audit/feedback was removed and decreased from 19.9% to 14.5% (difference −6.4%; 95% CI −8.6% to −4.2%) where audit/feedback was retained. The adjusted absolute difference in treatment effect was −2.6% (95% CI −5.4% to −0.1%; p = 0.0336). Study limitations included an unexpected reduction in testing across all groups impacting statistical power, loss of 4 clinics after randomisation, and inclusion of rural clinics only. Conclusions Audit/feedback is more effective than financial incentives of AU$5–AU$8 per chlamydia test at sustaining GP chlamydia testing practices over time in Australian general practice. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614000595617

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“…We can target feedback to those who previously open reports and remind them about their prior opening patterns. However, low overall opening rates, and lack of detectable improvement in antibiotic prescribing, suggest that more behavioral science research is needed to further encourage clinicians to open their feedback reports [ 15 , 30 ]. In particular, we must learn ways to target the nonopeners who do not already engage with their reports, such that they will have an opportunity to interact with the data and optimize their antimicrobial prescribing practices.…”

Section: Discussionmentioning

confidence: 99%

“…To be most effective, audit and feedback should be simple, timely, repeated, regular, and transmitted from an identified and respected source and should contain a clear, actionable message with thoughtful comparisons [ 15 ]. Our audit and feedback report itself was developed with input from infectious diseases, implementation science, information technology, and quality improvement specialists, and then improved through an iterative, user-centered design process as previously described [ 7 ].…”

Section: Methodsmentioning

confidence: 99%

Behavioral Nudges to Improve Audit and Feedback Report Opening Among Antibiotic Prescribers: A Randomized Controlled Trial

Daneman

Lee²,

Bai

et al. 2022

Open Forum Infectious Diseases

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Background Peer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested three behavioral nudging techniques delivered by email to improve report opening. Methods We conducted a pragmatic randomized controlled trial among Ontario long-term care (LTC) prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions. Results The trial included 421 physicians caring for more than 28,000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio (OR) 1.51 (95%CI 1.10-2.07, p=0.011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR (aOR) 1.74 (95%CI 1.24-2.45, p=0.0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR 1.62, 95%CI 1.06-2.47, p=0.026; aOR 2.16, 95%CI 1.33-3.50, p=0.0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR 1.28, 95%CI 1.14-1.43, p<0.001). Conclusions Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback.

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Details matter: predicting when nudging clinicians will succeed or fail

Abstract: Subtle implementation details can greatly influence the effectiveness of behavioural nudges because of their inherent subjective and social nature, argue Craig Fox and colleagues

Cited by 36 publications

References 30 publications

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

The impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice: A cluster randomised controlled trial (ACCEPt-able)

Behavioral Nudges to Improve Audit and Feedback Report Opening Among Antibiotic Prescribers: A Randomized Controlled Trial

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