Effectiveness of nudges as a tool to promote adherence to guidelines in healthcare and their organizational implications: A systematic review

https://doi.org/10.1016/j.socscimed.2021.114321Get rights and content

Highlights

  • Review of the literature linking nudges to adherence to guidelines in healthcare.

  • The literature largely suggests that nudges promote adherence to guidelines.

  • The review reveals several research gaps in the existing literature.

  • Directions for future research are presented.

Abstract

The shift in the United States in recent years toward value-based healthcare delivery models has brought renewed pressure on healthcare organizations to improve adherence to clinical and administrative guidelines designed to deliver high quality care at lower costs. However, getting clinicians to adhere to these guidelines remains a persistent problem for many organizations. The use of nudges has emerged as a popular intervention in healthcare settings to promote adherence to both sets of guidelines. This systematic review aims to assess the empirical evidence base on the use of various types of nudges and their effectiveness as a tool to promote this adherence and to identify the boundary conditions under which they are effective. In our assessment of 83 empirical studies, we found compelling evidence that nudges are an effective tool for promoting adherence to guidelines. However, much of this evidence relies heavily on studies focused on three types of nudges (increasing salience, providing feedback, and default). Other types of nudges (anticipated error reduction, structuring of complex problems, and understanding mapping) received far less attention. We also found that this literature is primarily focused on whether nudge interventions work, with little consideration for organizational issues such as cost effectiveness, impact on healthcare workers, and disruptions of established workflows and routines. We offer observations and recommendations on how research at the intersection of organizational studies and health services can improve our understanding of nudge interventions.

Introduction

The shift in the United States in recent years toward value-based healthcare delivery models has brought renewed pressure on healthcare organizations to improve adherence to clinical and administrative guidelines designed to deliver high quality care at lower costs. Under these models, revenue is generally tied to reported metrics of clinical quality in such a way as to ensure clinicians adhere to evidence-based clinical practice guidelines and standards of care while also ensuring documentation of all relevant details (Ellis, 2018). However, getting clinicians to adhere to both the clinical guidelines to improve care and to administrative guidelines to improve nonclinical outcomes remains a persistent problem for many healthcare organizations (Lorenzetti et al., 2018; O'Reilly-Shah et al., 2018).

For example, inappropriate or unnecessary prescription of antibiotics is associated with unnecessary risk of adverse drug events, increased healthcare costs, and the prevalence of antibiotic resistant bacteria (Fleming-Dutra et al., 2016; Meeker et al., 2014). Yet, despite published clinical guidelines and decades of efforts to change prescribing patterns, the problem of unnecessary prescription of antibiotics persists in many healthcare settings (Meeker et al., 2016). According to governmental agencies such as the United States Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC), nearly one in four antibiotic prescriptions in the United States are unnecessary and each year, at least 2 million people are infected with antibiotic-resistant bacteria, about 23,000 people die as a result, and antibiotic resistant infections contribute about $20 billion to direct healthcare costs (AHRQ, 2019; CDC, 2021).

The use of nudges, either alone or as part of multicomponent interventions, has shown promise in promoting adherence to both clinical and administrative guidelines (Yoong et al., 2020). Nudges are defined as subtle changes in how choices are presented that can significantly influence a decision maker's behavior in predictable ways without restricting choices or changing economic incentives (Thaler and Sunstein, 2008). For example, in order to reduce inappropriate or unnecessary antibiotic prescriptions, clinicians' choices can be influenced if they are presented with preset options (i.e., defaults) in an electronic order entry system.

From a policy-making perspective, nudges are attractive because they influence behavior without the use of regulatory processes or economic incentives. From an organizational perspective, nudges are attractive because they involve relatively cheap, small, and generally palatable adjustments to operational workflows (Gill, 2018). And unlike alternative strategies to promote adherence to guidelines such as system reengineering and business process redesign or training and education, nudges do not have disadvantages such as imposing workflow restrictions that may disrupt the way clinicians perform their tasks. Moreover, once implemented, nudges are likely to perpetually influence behavior without additional reinforcement. Consequently, behavioral changes are less likely to decline to baseline levels over time as is the case with other interventions such as training and education (Kaiser et al., 2019; Stander et al., 2019).

These advantages of nudges have inspired a growing number of research projects that have investigated their effectiveness in promoting adherence to guidelines in healthcare. In turn, the growing popularity of nudge-based studies has resulted in two attempts that we know of to provide a systematic review of the evidence base for their effectiveness (Nagtegaal et al., 2018; Yoong et al., 2020). Although these reviews made important contributions, they were limited by their research approaches. For example, whereas Nagtegaal et al. (2018) conducted a scoping review that described the reviewed material without critically appraising individual studies or rigorously synthesizing evidence from different studies to assess their organizational implications, Yoong et al. (2020) reviewed literature review articles and thus did not examine the original research studies. These two approaches raise questions about the research implications of difficult tradeoffs between the breadth (covering all available material) and depth (detailed analyses and appraisals of a smaller number of studies) of the articles reviewed (Arksey & O'Malley, 2005). Moreover, the application of nudges has been examined across a variety of contexts—different care settings (e.g., primary care vs. emergency departments), task types (e.g., clinical vs. administrative tasks), provider-level demographic groups (e.g., nurses vs. physicians or experienced vs. inexperienced clinicians), and adopted different units of randomization (e.g., patient, unit, or organizational levels). However, existing reviews have made little attempt to synthesize and identify associations between the efficacy of nudges (or lack thereof) and the contexts in which they were applied. Without such considerations, our knowledge of the effectiveness of nudges to promote adherence to guidelines is likely to remain limited.

Management research in fields such as organizational theory, organizational behavior, management information systems, and operations management emphasizes that decision-making and behavior depend largely on context or situational settings in which workplace phenomena occur (Cooper et al., 2014; Joshi and Roh, 2009). For example, clinicians in different care settings characterized by different levels of workloads or urgency of care (e.g., emergency room vs. primary care) may make different decisions when exposed to the same intervention. Likewise, individual attributes such as experience and task attributes (e.g., clinical vs. administrative tasks) have been shown to affect decision-making and behavior (McElroy and Dowd, 2007; Speier et al., 2003). Further, because nudges are not monolithic—in the sense that they are of different types—and their implementation often triggers new situations that decision makers may experience differently (Thaler and Sunstein, 2008), different types of nudges may generate different responses among decision makers.

These responses could also differ by work contexts, likely resulting in person-situation variations in the efficacy of different nudge types (Johns, 2006). Moreover, because organizations tend to have resource constraints (e.g., time, money, skills) that must be balanced against competing priorities and different nudge types impose different demands on organizational resources, nudges are likely to unintendedly affect organizational processes and performance outcomes over and above their effects on adherence to guidelines.

All these aspects of nudges suggest that their effects on adherence to guidelines may differ according to factors such as type, organizational context, tasks, and clinicians’ attributes. They may also result in unintended consequences that can enhance or diminish their overall benefits. Thus, if we are to better understand the efficacy of nudges as a tool to promote adherence to guidelines and to inform managers of appropriate application conditions for these interventions, we must identify opportunities to integrate ideas from the foundational fields of nudges—psychology and behavioral economics—with organizational theories. Such endeavors should provide insights into how to effectively design and implement nudges in organizations; they also should provide a framework through which researchers can identify mechanisms that explain the effects of nudges on behavioral and organizational outcomes. Cross-fertilization of these research disciplines could also shed light on spillover effects, unintended consequences on organizational processes, and how to manage them.

Accordingly, our primary objective here is to present a systematic review of studies that have assessed the effectiveness of various kinds of nudges in improving clinicians’ adherence to guidelines. In addition to assessing the evidence base on the effectiveness of nudges for this purpose, we also have undertaken to identify whether the contexts in which nudges are applied affect their effectiveness. Achieving this primary objective requires a focus on studies that have quantitatively assessed behavioral changes in adherence to guidelines because of nudge interventions. A secondary objective is to identify research opportunities at the intersection of foundational theories for nudges and organizational fields that may advance our understanding of how to design and implement nudges that effectively promote adherence to guidelines and also inform theory-guided explanations for the organizational impact of nudges. Achieving this secondary objective requires careful assessment of the scientific evidence of the effects of nudges across different contexts.

Our study departs from its predecessors in notable ways. Unlike their focus primarily on adherence to clinical guidelines, our focus is on both the clinical and administrative guidelines involved in delivering healthcare. This dual focus is necessary to ascertain if the same nudges that are effective with adherence to clinical guidelines are equally effective with adherence to administrative guidelines. Second, we have gone beyond the previous research that was mostly preoccupied with atheoretical approaches narrowly focused on behavioral outcomes and sought insight into the conditions under which nudges promote adherence to guidelines. We also have assessed the organizational impacts and issues associated with implementation of these nudges, topics largely unaddressed in previous research. In pursuing a more holistic approach to designing and implementing nudges in healthcare, we aim to identify opportunities for cross-fertilization of theoretical ideas from the well-established literature in psychology, behavioral economics, and organizational behavior and theory. This approach should also provide researchers and practitioners with broader perspectives to use in assessing and explaining the effectiveness of nudges in healthcare environments.

Our study makes two major contributions to the literature. First is our synthesis of a fragmented body of work and our identification of conditions under which nudges are likely to improve adherence to guidelines. Such a synthesis and assessment of the varieties of nudges available and the conditions under which they work best is essential to effective design of nudges. Without a comprehensive assessment of the variety of nudge interventions available and the conditions under which they are effective, it is difficult to design effective interventions and challenging to identify contextual factors that determine their success or failure. Thus, we provide a repository of evidence on the use of nudges to promote clinicians’ adherence to clinical and administrative guidelines.

Second, by advocating for a holistic approach in investigating the effectiveness of nudges, we also contribute to the literature by identifying key knowledge gaps that can be filled by cross-disciplinary research at the intersection of health services research and organizational studies. Few theory-based explanations exist to guide the more in-depth research investigations needed to advance beyond simple observations of “what nudges work” to a contextually situated understanding of “when nudges work”, while expounding on their relative effects across various actors or settings. Throughout our discussion, we have highlighted several avenues future research can take to address these gaps in the literature. Our conclusions inform healthcare administrators and policymakers of the importance of adopting much broader perspectives on the use of nudges to promote adherence to clinical and administrative guidelines and put forward research directions in this area.

Section snippets

Nudges

The concept of nudges originated in the behavioral economics discipline and in recognition that when faced with prediction problems, decision makers often rely on simple heuristics or rules-of-thumb. This sort of reliance tends to result in cognitive biases, or predictable distortions in decision-making that can ultimately result in suboptimal outcomes (Thaler, 2018; Tversky and Kahneman, 1974). For example, although it seems rational that clinicians operating under value-based payment models

Methodology

This review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009).

General study characteristics

Table S-1 in the online supplement presents a descriptive summary of the 83 studies identified in our search. Of the 83 studies in the final review, 41 (49.39%) were conducted in North America (U.S. with 45.78% and Canada with 3.61%). Twenty-seven (32.53%) were from Europe (the U.K., Denmark, Germany, Norway, Switzerland, the Netherlands, Spain, and Sweden); two were from Australasia (2.40%), and five studies (6.02%) were reported from non-Western nations (Argentina, Ghana, Hong Kong, Iran, and

Discussion

Our review of the literature on the use of nudge interventions to promote adherence to clinical and administrative guidelines reveals that researchers have examined all six nudge strategies identified in the Thaler and Sunstein (2008) framework. In decreasing order, the frequency of investigations into the interventions was: IS, PF, DF, ER, SC, and UM. We found this evidence base on the effectiveness of nudges to be compelling. However, we note that much of this evidence relies on studies

References (57)

  • Centers for Disease Control and Prevention | Improve Antibiotic Use | 6|18 Initiative

    (2021, May 26)
  • B.P. Chan et al.

    Effect of varying the number and location of alcohol-based hand rub dispensers on usage in a general inpatient medical unit

    Infect. Contr. Hosp. Epidemiol.

    (2013)
  • D. Cooper et al.

    It depends: environmental context and the effects of faultlines on top management team performance

    Organ. Sci.

    (2014)
  • P.R. Dexter et al.

    A computerized reminder system to increase the use of preventive care for hospitalized patients

    N. Engl. J. Med.

    (2001)
  • R. Ellis

    Value-Based Care and Evidence-Based Care: One and the Same

    (2018, May 18)
  • K.E. Fleming-Dutra et al.

    Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011

    Jama

    (2016)
  • A.W. Fogarty et al.

    Hospital clinicians' responsiveness to assay cost feedback: a prospective blinded controlled intervention study

    JAMA Intern. Med.

    (2013)
  • S. Gephart et al.

    A systematic review of nurses' experiences with unintended consequences when using the electronic health record

    Nurs. Adm. Q.

    (2015)
  • S. Ghoshal et al.

    Linking organizational context and managerial action: the dimensions of quality of management

    Strat. Manag. J.

    (1994)
  • D. Gill

    How to Spot a Nudge Gone Rogue

    (2018)
  • P.G. Hansen

    The definition of nudge and libertarian paternalism: does the hand fit the glove?

    Eur. J. Risk Reg.

    (2016)
  • S.L. Harriman et al.

    When are clinical trials registered? An analysis of prospective versus retrospective registration

    Trials

    (2016)
  • J.P. Higgins et al.

    The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

    BMJ

    (2011)
  • T.A. Holt et al.

    Automated electronic reminders to facilitate primary cardiovascular disease prevention: randomised controlled trial

    Br. J. Gen. Pract.

    (2010)
  • J. Isojarvi et al.

    Challenges of identifying unpublished data from clinical trials: getting the best out of clinical trials registers and other novel sources

    Res. Synth. Methods

    (2018)
  • G. Johns

    The essential impact of context on organizational behavior

    Acad. Manag. Rev.

    (2006)
  • A. Joshi et al.

    The role of context in work team diversity research: a meta-analytic review

    Acad. Manag. J.

    (2009)
  • S.V. Kaiser et al.

    Feasible strategies for sustaining guideline adherence: cross-sectional analysis of a national collaborative

    Hosp. Pediatr.

    (2019)
  • Cited by (18)

    • Towards reinforcing the waste separation at source for Vietnam's waste management: Insights from the Nudge Theory

      2023, Environmental Challenges
      Citation Excerpt :

      In the selection of specific articles for this review work, the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was followed because it has been considered as a standard framework for transparency in review works (Nwafor et al., 2021). It also exhibits a systematic approach for the final selection of published quality reports for review as demonstrated in the work of Nwafor et al. (2021). For this matter, 103 articles in total were found in the database including the cases published for other countries in the application of nudges.

    • Using nudges to promote clinical decision making of healthcare professionals: A scoping review

      2022, Preventive Medicine
      Citation Excerpt :

      In recent years, a shift towards new healthcare delivery models has brought renewed pressure to adhere to clinical and administrative guidelines in an effort to improve quality and reduce costs (Nwafor et al., 2021).

    • Can “Nudging” Play a Role to Promote Pro-Environmental Behaviour?

      2021, Environmental Challenges
      Citation Excerpt :

      However, it was found that there is lack of literature that specifically review nudging techniques and propose for pro-environmental context. Most of the reviews on nudging topic for promoting behavioural change were found in health-related contexts such as healthy dietary behaviour (Cesareo et al., 2021; Laiou et al., 2021; Marcano‐Olivier et al., 2020; Harbers et al., 2020; Broers et al., 2017; DeCosta et al., 2017; Nørnberg et al., 2016; Bucher et al., 2016; Arno and Thomas, 2016), healthy lifestyle behaviour (Laiou et al., 2021; Landais et al., 2020; Ledderer et al., 2020) and healthcare behaviour (Nwafor et al., 2021; Wang and Groene, 2020; Yoong et al., 2020; Möllenkamp et al., 2019). Whereas, for nudging pro-environmental behaviour, only one review was found, which was the review by Byerly et al. (2018).

    View all citing articles on Scopus
    View full text