Physician organizations' use of behavioral nudges to influence physician behavior

Because physicians' decisions drive health care costs and quality, there is growing interest in applying behavioral economics approaches, including behavioral nudges, to influence physicians' decisions. This paper investigates adoption of behavioral nudges by health system-affiliated physician organizations (POs), types of nudges being used, PO leader perceptions of nudge effectiveness, and implementation challenges.

Mixed-methods study design (PO leader survey followed by in-depth qualitative interviews). Purposive sample of 30 health system-affiliated POs in 4 states; POs varied in size and quality performance.

We collected data between October 2017 and June 2019. The survey asked PO leaders to report their organization's use of 5 categories of nudges to influence primary and specialty physicians' actions. We conducted semistructured phone interviews to confirm survey responses, elicit examples of the nudges that POs reported using, understand how nudges were structured, and identify implementation challenges. We present descriptive tabulations of nudge use and effectiveness ratings. We applied thematic analysis to the interview data.

Almost all POs in this study reported nudge use. Clinical templates, patient action lists, and altered order entry were most commonly used. However, PO leaders reported that nudge use was limited to a narrow range of clinical applications, not widespread across the organization, and mostly structured as suggestions rather than default actions or hard stops.

Nudge use remains limited in practice. Opportunities exist to expand use of nudges to influence physician behavior; however, expanding use of behavioral nudges will require PO investment of resources to support their construction and maintenance.