Summary
Cognitive biases in decision making may make it difficult for clinicians to reconcile evidence of overuse with highly ingrained prior beliefs and intuition.
Such biases can predispose clinicians towards low value care and may limit the impact of recently launched campaigns aimed at reducing such care.
Commonly encountered biases comprise commission bias, illusion of control, impact bias, availability bias, ambiguity bias, extrapolation bias, endowment effects, sunken cost bias and groupthink.
Various strategies may be used to counter such biases, including cognitive huddles, narratives of patient harm, value considerations in clinical assessments, defining acceptable levels of risk of adverse outcomes, substitution, reflective practice and role modelling, normalisation of deviance, nudge techniques and shared decision making.
These debiasing strategies have considerable face validity and, for some, effectiveness in reducing low value care has been shown in randomised trials.
Promising interventions include audit and feedback, system-based changes, and education. Future researchers should move beyond before-after designs to rigorously evaluate interventions. A relatively novel approach will be to include both clinicians and the families they manage in such interventions.
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 .MethodsAustralian 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.Results120 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).InterpretationA 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.
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