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BMJ Qual Saf. 2018 Nov 19. pii: bmjqs-2018-008659. doi: 10.1136/bmjqs-2018-008659. [Epub ahead of print]

Effect of two behavioural 'nudging' interventions on management decisions for low back pain: a randomised vignette-based study in general practitioners.

Author information

1
Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia tsoo7799@uni.sydney.edu.au.
2
Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
3
Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
4
Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
5
Centre for Research in Evidence-Based Practice (CREBP), Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, Australia.
6
School of Public Health, University of Sydney, Sydney, New South Wales, Australia.

Abstract

OBJECTIVE:

'Nudges' are subtle cognitive cues thought to influence behaviour. We investigated whether embedding nudges in a general practitioner (GP) clinical decision support display can reduce low-value management decisions .

METHODS:

Australian GPs completed four clinical vignettes of patients with low back pain. Participants chose from three guideline-concordant and three guideline-discordant (low-value) management options for each vignette, on a computer screen. A 2×2 factorial design randomised participants to two possible nudge interventions: 'partition display' nudge (low-value options presented horizontally, high-value options listed vertically) or 'default option' nudge (high-value options presented as the default, low-value options presented only after clicking for more). The primary outcome was the proportion of scenarios where practitioners chose at least one of the low-value care options.

RESULTS:

120 GPs (72% male, 28% female) completed the trial (n=480 vignettes). Participants using a conventional menu display without nudges chose at least one low-value care option in 42% of scenarios. Participants exposed to the default option nudge were 44% less likely to choose at least one low-value care option (OR 0.56, 95%  CI 0.37 to 0.85; p=0.006) compared with those not exposed. The partition display nudge had no effect on choice of low-value care (OR 1.08, 95%  CI 0.72 to 1.64; p=0.7). There was no interaction between the nudges (OR 0.94, 95%  CI 0.41 to 2.15; p=0.89).

INTERPRETATION:

A default option nudge reduced the odds of choosing low-value options for low back pain in clinical vignettes. Embedding high value options as defaults in clinical decision support tools could improve quality of care. More research is needed into how nudges impact clinical decision-making in different contexts.

KEYWORDS:

clinical; cognitive biases; decision support; evidence-based medicine; general practice; low back pain; randomised controlled trial

PMID:
30455177
DOI:
10.1136/bmjqs-2018-008659

Conflict of interest statement

Competing interests: None declared.

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