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Effect of two behavioural ‘nudging’ interventions on management decisions for low back pain: a randomised vignette-based study in general practitioners
  1. Jason Soon1,
  2. Adrian C Traeger2,
  3. Adam G. Elshaug1,
  4. Erin Cvejic3,
  5. Chris G Maher2,
  6. Jenny A Doust4,
  7. Stephanie Mathieson2,
  8. Kirsten McCaffery3,
  9. Carissa Bonner5
  1. 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
  2. 2 Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
  3. 3 Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
  4. 4 Centre for Research in Evidence-Based Practice (CREBP), Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, Australia
  5. 5 School of Public Health, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Jason Soon, Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NS 2006, Australia; tsoo7799{at}uni.sydney.edu.au

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.

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

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Footnotes

  • Contributors JS,AT and CB conceived the idea. All authors contributed to refinement of the study design. JS, AT, CB and EC acquired the data and performed the statistical analysis. All authors interpreted the data. JS wrote the initial draft of the paper. All authors revised the paper critically for important intellectual content and approved the final version.

  • Funding This work was supported by the National Health and Medical Research Council (NHMRC) ‘Wiser Healthcare’ Research Program Grant (APP1113532). AT was supported by an NHMRC Early Career Fellowship (APP1126082). CB was supported by National Heart Foundation of Australia Vanguard Grant 101326. CM was supported by an NHMRC Principal Research Fellowship (APP 1103022).AGE holds a HCF Research Foundation Professorial Fellowship.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Royal Prince Alfred Hospital Ethics Review Committee (Approval number HREC/18/RPAH/138).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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