Quality

Behavioral Economics Can Accelerate Adoption of Choosing Wisely Campaign



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Table 2. MINDSPACE Behavior Cue1

SHM has gotten behind the Choosing Wisely campaign in a big way. Earlier this year, SHM announced lists of suggested practices for adult and pediatric hospital medicine (see Table 1). To keep it on the front burner, hospitalists John Bulger and Ian Jenkins held a pre-course at HM13 devoted entirely to quality-improvement (QI) approaches to implementing and sustaining the practices outlined in the campaign. During the main meeting, they did an encore presentation, with Doug Carlson and Ricardo Quinonez presenting the elements of Choosing Wisely for pediatric hospital medicine.

Table 1. Choosing Wisely Campaign Recommendations for Hospitalists

ADULT HM

  • DON’T PLACE, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically-ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis).
  • DON’T PRESCRIBE medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
  • AVOID TRANSFUSIONS of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
  • DON’T ORDER continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
  • DON’T PERFORM repetitive CBC and chemistry testing in the face of clinical and lab stability.

PEDIATRIC HM

  • DON’T ORDER chest radiographs in children with uncomplicated asthma or bronchiolitis.
  • DON’T ROUTINELY USE bronchodilators in children with bronchiolitis.
  • DON’T USE systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.
  • DON’T TREAT gastroesophageal reflux in infants routinely with acid suppression therapy.
  • DON’T USE continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

The widely publicized campaign arose from an American Board of Internal Medicine (ABIM) Foundation grant program to “facilitate the development of innovative, emerging strategies to advance appropriate health-care decision-making and stewardship of health-care resources.” (For more information, visit www.abimfoundation.org.)

Adoption of many of the suggested Choosing Wisely practices will require a change in deeply ingrained, habitual behaviors. We assert that rational, reflective, cognitive processes might not be enough to overturn these behaviors, and that we must look to other mental systems to achieve the consistent adoption of the campaign’s suggested practices. An analogy exists in economics, where theories behind classical economics are challenged by behavioral economics.

What is behavioral economics? Classical economics asserts the individual as “homo economicus”: a person making rational, predictable decisions to advance their interests. However, due to social or professional influence, behavior often does not comport to expected ends. We succumb, sympathize, or follow the pack, diverging from the rulebook. Behavioral economics attempts to understand and compensate for these deviations.

In medicine, we often yield to cognitive biases. To simplify decision-making, we generalize our observations to arrive at decisions quickly. Daniel Kahneman, winner of the Nobel Memorial Prize in Economic Sciences, describes Type I thinking as fast and automatic, and Type II thinking as slow and effortful. Using Kahneman’s framework, we attempt to understand where reasoning may stray and, in turn, introduce environmental changes to achieve better outcomes.

How does this relate to Choosing Wisely? Embracing and embedding the practices of the Choosing Wisely campaign in day-to-day practice will require change in how we approach the clinical decisions we make each day. How can we create the conditions so as not to yield to the status quo?

The MINDSPACE framework

King et al in a recent Health Affairs article describe the MINDSPACE framework (see Table 2), which captures nine effects on behavior—messenger, incentives, norms, defaults, salience, priming, affect, commitments, and ego—that mostly involve automatic systems (Kahneman’s Type I), and how we can leverage them to minimize ineffective health care.1 Below, we describe Choosing Wisely’s HM components and how MINDSPACE can help promote better practice.

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