Default Nudges in Medicine—Designing the Right Choice

Abstract

Defaults work. With defaults, a designer or "choice architect" alters the environment and provides a preselected option. 1 An individual must take action to avoid the default occurring. Defaults might be described as making the right choice the easy choice. Although universal agreement on what constitutes "the right choice" is not necessary, defaults should target actions or events about which broad consensus exists. Defaults should preserve individual choice for the target of the action, enable those who do not want to take the action to easily opt out, and occur at a time and setting that make sense for the recipient and the action. Defaults should be transparent or risk being perceived as sneaky and eroding trust.Outside medicine, defaults have been used to increase organ donation, retirement plan enrollment, use of green energy, and healthy food selection. In medicine, defaults-notably those embedded in the electronic health record-have been used to increase vaccinations, increase generic drug prescribing, decrease opioid prescribing amounts, decrease unnecessary imaging, and increase cancer screening. 2What about a default to increase hepatitis C virus (HCV) screening? Hepatitis C virus infection is the leading cause of cirrhosis in the US. Owing to HCV's associated morbidity and mortality, the Centers for Disease Control and Prevention has made recommendations on HCV screening since 1998. The most recent expansion of screening guidelines in 2020 include 1-time HCV screening for all nonpregnant adults. Despite these recommendations, most eligible US residents have not been screened, and effective interventions to improve screening and treatment are needed. 3 To increase screening, some states have implemented laws on HCV screening. Since 2016, a Pennsylvania law has mandated offering HCV screening to adults born between 1945 and 1965-the target of earlier HCV screening recommendations-in primary care and inpatient settings. To better adhere to Pennsylvania law and increase screening, Mehta et al 4 conducted a stepped-wedge randomized clinical trial in 2 academic Pennsylvania hospitals; results are published elsewhere in JAMA Network Open.The intervention embedded a default HCV laboratory order within admission order sets. The order included text reminding clinicians of the state mandate and that positive results would be followed up by a dedicated hepatitis linkage team. The intervention was compared with a pop-up alert that included information about the state mandate and that positive test results would be analogously followed up by the hepatitis linkage team; clinicians were required, in 1 click, to either accept the laboratory order or dismiss the alert and order.With the pop-up alert comparison, HCV tests were ordered for 38.7% of admitted patients, and screening was completed for 34.9%. The default intervention increased laboratory ordering by 38.1 percentage points to 2599 of 3229 patients (80.5%); screening completion increased by 31.8 percentage points to 2257 of 3220 patients (69.9%). The intervent...

The devil’s in the defaults: An interrupted time-series analysis of the impact of default duration elimination on exposure to fluoroquinolone therapy

“…This has been confirmed both outside of healthcare with financial choices, food selection, and energy choices as well as those within healthcare, with increased vaccination, screening, and decreased unneeded imaging. 42,43 Change is more difficult when a decision appears to be made with a defaulted choice. The challenge with defaults is making "the right choice" in setting the duration that is appropriate for the patient and location.…”