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• Beware the pitfalls of nudge theory
  Oliver J David
  Published on: 11 January 2019

• Published on: 11 January 2019

  Beware the pitfalls of nudge theory

  • Oliver J David, Anaesthetist Lyell McEwin Hospital, South Australia

  O’Reilly-Shah et al. present a novel approach to quality improvement in anaesthesia by attempting to elicit change in practice using ‘nudge theory’ derived from the field of behavioural economics [1]. Translating new research evidence into common clinical practice is an important quality issue and cheap and effective strategies to achieve this are of interest. O’Reilly-Shah et al. hypothesised that using ‘nudge-type’ interventions, an audit-feedback dashboard as well as changes to mechanical ventilator default settings, might improve anaesthesia provider compliance with this ‘lung protective’ ventilation strategy in the general operating theatre environment.
  I disagree with the conclusion that the authors have drawn, that these interventions might improve clinical and financial outcomes. My disagreement stems from the clinical rationale of the intervention, which overlaps onto the assumptions built into the ‘nudge theory’ of behavioural economics itself.
  Sunstein & Thaler, who have influenced large scale policy making in several countries, describe nudge theory as a form of choice architecture that “alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives” [2, 3]. Their philosophy is described as “libertarian paternalism”, as it influences choices that make people better off as judged by themselves, while preserving their freedom to choose otherwise. This is presumably what the interve...

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  O’Reilly-Shah et al. present a novel approach to quality improvement in anaesthesia by attempting to elicit change in practice using ‘nudge theory’ derived from the field of behavioural economics [1]. Translating new research evidence into common clinical practice is an important quality issue and cheap and effective strategies to achieve this are of interest. O’Reilly-Shah et al. hypothesised that using ‘nudge-type’ interventions, an audit-feedback dashboard as well as changes to mechanical ventilator default settings, might improve anaesthesia provider compliance with this ‘lung protective’ ventilation strategy in the general operating theatre environment.
  I disagree with the conclusion that the authors have drawn, that these interventions might improve clinical and financial outcomes. My disagreement stems from the clinical rationale of the intervention, which overlaps onto the assumptions built into the ‘nudge theory’ of behavioural economics itself.
  Sunstein & Thaler, who have influenced large scale policy making in several countries, describe nudge theory as a form of choice architecture that “alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives” [2, 3]. Their philosophy is described as “libertarian paternalism”, as it influences choices that make people better off as judged by themselves, while preserving their freedom to choose otherwise. This is presumably what the interventions chosen by O’Reilly-Shah et al. were based on, that changing ventilator defaults did not force anaesthetists to select a certain tidal volume, and audit-feedback dashboards might foster change through an increase in awareness of peer group behaviour.
  Assessing preferences and costs may not be straightforward, as described in a critique of nudge theory by Berg & Davidson [3]. They argue that many choice decisions implicitly have a trade-off, and it is difficult to predict in advance which direction the balance tips. Furthermore, selecting a particular tidal volume (a continuous variable) for a particular patient during an operation might be a complex decision and not a binary option, which makes the cost or indeed the opportunity cost, of a particular choice difficult to ascertain, in economic parlance.
  A study much vaunted by the New York Times Magazine demonstrating improvement in hand hygiene rates amongst clinicians after the introduction of screen savers depicting bacterial cultures from physicians’ hands, failed to be replicated in another study using a similar methodology, which suggests that audit-feedback dashboard techniques may not be robust [4, 5]. O’Reilly-Shah et al. state that most practitioners accepted the target ventilation strategy without debate but they also admit that there is equipoise in the anaesthetic literature regarding the benefit of a low-tidal volume strategy for elective surgical patients [1]. As such, the increased compliance rate might not have reflected the provider’s ‘better preference’ per se, but a trend towards the default lower tidal volume as it may not have been an important factor either way.
  A better example using the authors’ approach might be the default setting of ‘pressure-controlled’ ventilation as opposed to ‘volume-controlled’ ventilation in paediatric patients undergoing general anaesthesia, to avoid the danger of delivering overtly dangerous large tidal volumes. This is sensible practice in paediatric, but in hospitals with mixed adult and paediatric populations, this may not always be appropriate. It would then represent a binary decision and the benefit would be more obvious.

  References
  1. O'Reilly-Shah VN, Easton GS, Jabaley CS, Lynde GC. Variable effectiveness of stepwise implementation of nudge-type interventions to improveprovider compliance with intraoperative low tidal volume ventilation. BMJ Qual Saf. 2018 May 18
  2. Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, And Happiness. New Haven : Yale University Press, 2008, p5-6.
  3. Berg C, Davidson S. Nudging, calculation, and utopia, Journal of Behavioral Economics for Policy, Vol. 1, Special Issue, 49-52, 2017
  4. Dubner SJ, Levitt SD. Selling soap. The New York Times Magazine, September 24, 2006.
  5. Charters M, Cheng AL, Esaki RK, Kuo AS, Neal J, Thawani JP, Chenoweth C. The impact of a screensaver in promoting hand hygiene. Am J Infect Control. 2009 Dec;37(10):867-8

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  Conflict of Interest:
  None declared.

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