Kostick Kristin M, Trejo Meredith, Volk Robert J, Estep Jerry D, Blumenthal-Barby J S
Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas.
Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas.
MDM Policy Pract. 2020 Apr 26;5(1):2381468320915906. doi: 10.1177/2381468320915906. eCollection 2020 Jan-Jun.
Although effective interventions for shared decision making (SDM) exist, there is a lack of uptake of these tools into clinical practice. "Nudges," which draw on behavioral economics and target automatic thinking processes, are used by policy makers to influence population-level behavior change. Nudges have not been applied in the context of SDM interventions but have potential to influence clinician motivation, a primary barrier to long-term adoption of SDM tools. Describe, evaluate, and propose recommendations for the use of a behavioral economics framework (MINDSPACE) on clinician motivation and behavior during implementation of a validated decision aid (DA) for left ventricular assist device at nine hospitals. Qualitative thematic analysis of process notes from stakeholder meetings during the first 6 months of implementation to identify examples of how the MINDSPACE framework was operationalized. Quantitative implementation progress was evaluated using the RE-AIM framework. MINDSPACE components were translated into concrete approaches that leveraged influential stakeholders, fostered ownership over the DA and positive emotional associations, spread desirable norms across sites, and situated the DA within established default processes. DA reach to eligible patients increased from 9.8% in the first month of implementation to 70.0% in the sixth month. Larger gains in reach were observed following meetings using MINDSPACE approaches. The MINDSPACE framework does not capture all possible influences on behavior and responses to nudges may differ across populations. Behavioral economics can be applied to implementation science to foster uptake of SDM tools by increasing clinician motivation. Our recommendations can help other researchers effectively apply these approaches in real-world settings when there are often limited incentives and opportunities to change organizational- or structural-level factors.
尽管存在有效的共享决策（SDM）干预措施，但这些工具在临床实践中的应用并不广泛。“助推”借鉴行为经济学并针对自动思维过程，政策制定者利用它来影响人群层面的行为改变。“助推”尚未应用于SDM干预措施的背景中，但有可能影响临床医生的积极性，而这是长期采用SDM工具的主要障碍。描述、评估并建议在九家医院实施经验证的左心室辅助装置决策辅助工具（DA）期间，如何使用行为经济学框架（MINDSPACE）来影响临床医生的动机和行为。对实施前6个月利益相关者会议的过程记录进行定性主题分析，以确定MINDSPACE框架如何实施的实例。使用RE-AIM框架评估定量实施进展。MINDSPACE的组成部分被转化为具体方法，这些方法利用有影响力的利益相关者，培养对决策辅助工具的所有权和积极的情感联想，在各地点传播理想的规范，并将决策辅助工具置于既定的默认流程中。决策辅助工具对 eligible 患者的覆盖范围从实施第一个月的9.8%增加到第六个月的70.0%。使用MINDSPACE方法的会议之后，覆盖范围有更大的提升。MINDSPACE框架并未涵盖对行为的所有可能影响，而且对“助推”的反应可能因人群而异。行为经济学可应用于实施科学，通过提高临床医生的积极性来促进SDM工具的采用。我们的建议可帮助其他研究人员在改变组织或结构层面因素的激励措施和机会通常有限的现实环境中，有效地应用这些方法。
