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Using Behavioral Nudges for Quality Improvement

December 6, 2022

Many medications taken for chronic diseases, such as rheumatologic diseases, are teratogenic – meaning that they can lead to fetal malformations or pregnancy loss if they are taken during pregnancy.

Although adolescents with chronic disease are just as likely to be sexually active as their peers without chronic conditions, few are prescribed contraception.

A team of researchers at the Ohio State University and Baylor College of Medicine, led by Dr. Veronica Mruk, wanted to improve processes to prevent pregnancy in adolescents who were taking teratogenic medications. This week, Pediatrics is early releasing a Quality Report, entitled “Preventing Teen Pregnancies on Teratogenic Drugs by Quality Improvement and Behavioral Economics,” detailing their methods and results (10.1542/peds.2021-054294).

As suggested by the title, in addition to using quality improvement (QI) methods, the authors also used behavioral economic (BE) strategies, which use economics and psychology to promote behavior change. The “behavioral nudge” is a commonly used BE strategy.

Behavioral nudges are changes made in the decision environment to influence behavior and decision-making. For instance, a common behavioral nudge that pediatricians suggest to promote healthy eating is to put cut up fruit or vegetables at eye level in the refrigerator, so that’s the first thing one sees upon opening the refrigerator, and one is more likely to eat that because it is the easiest option. Common behavioral nudges aimed towards healthcare professionals include default options in the electronic medical record for prescribing medications that make the “preferred” decision the easiest option.

The authors’ first goal in this particular study was to increase the proportion of families who signed annual teratogenic medication consent, acknowledging that they understood the risks if the patient became pregnant while taking teratogenic medications. They used strategies such as supplying the provider with the consent form as they went into the patient room and printing the forms on brightly colored paper, so that they would not be forgotten during the visit.

Their second goal was to improve rates of sexual history screening and contraception counseling by the providers. They audited charts and provided feedback to the providers about their performance. This feedback included comparison to other providers, which created new social norms regarding routine sexual screening and counseling.

These strategies, combined with QI methodology, resulted in big improvements in annual consents (0% to 95%) and sexual history screening (2% to 78%). There were also impressive decreases in pregnancies among the patients taking teratogenic medications.

Read this Quality Report – it may give you ideas for how you can incorporate behavioral nudges to improve the quality of the care that you provide.

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