Moving From Activating Patients to Activating Systems to Improve Outcomes

Nearly half of patients with hypertension have poor blood pressure (BP) control,¹ and new guidelines that lower goal BP mean that even more Americans are at risk of having BP that is considered inadequately controlled. The study by Kaboli et al² focuses on the question of whether increased patient activation, defined by the authors as “imparting knowledge, skills, and confidence such that patients become more active and informed participants in the delivery of health care”² can be effectively used to increase thiazide prescribing and BP control.

Kaboli et al² randomized 598 participants from VA clinics to a control group or 1 of 3 intervention arms: an activation letter that provided customized information about BP goals and cardiovascular risk, the activation letter and a financial incentive of $20 for mailing in a postcard confirming conversation with one’s primary care physician and up to $48 in forgiven copayments for a thiazide diuretic over 6 months, or the activation letter and the financial incentive and a telephone call by a health educator encouraging conversation about BP with one’s primary care physician shortly before the visit.

Thiazide discussion rates were higher in the more intensive interventions: 44.1% with the activation letter alone, 56.3% in the group that received the activation letter and the financial incentive, and 68.7% in the group that received the activation letter, incentive, and call from a health educator. However, effects on BP were modest; only the intervention that combined all 3 approaches resulted in higher odds of good BP control at 12 months, and prescribing rates were quite similar between the control and intervention groups.

As defined by Thaler and Sunstein,³ nudges are defined as any aspect of choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, the intervention must be easy and cheap to avoid. Nudges are not mandates. The interventions by Kaboli et al² relied heavily on information provision and education, and that is often regarded as necessary but not sufficient in changing behavior. The tested interventions do not involve strong economic incentives or mandates; however, relying on patients to opt into a course of action was a challenging way to improve outcomes. Given the highly favorable benefit and risk ratio in prescribing thiazide diuretics, the intervention approach could be strengthened by making the desired behavior more automatic. For example, rather than sending a letter to a patient suggesting a conversation with his or her clinician about prescribing a thiazide diuretic, why not automatically order a thiazide diuretic for every patient with poorly controlled hypertension who does not have contraindications? Clinicians could be allowed to opt out. That would likely achieve very high rates of prescribing. Patel et al⁴ changed the default in physician order entry from brands to generics and found that generic prescribing rates immediately jumped to 99%; these results have now been sustained for more than 2 years.

If nudging or defaults are used to influence the behavior of either patients or clinicians, the ability to opt out is very important. The underlying ethos of behavioral economic interventions is libertarian paternalism,⁵ indicating that while these interventions are undeniably paternalistic it is important to preserve freedom of choice and to make it possible to opt out relatively easily. Removing freedom of choice and mandating thiazide diuretics, generics, or any other treatment to clinicians would likely generate a backlash and would have the significant downside of not allowing clinicians—when they have preferences or information suggesting that an alternative would be superior—to exercise their professional judgment in choosing that alternative. In the generic prescribing example described earlier, it was important to see that clinicians opted out of prescribing the generic form of levothyroxine for patients who had difficulty controlling hypothyroidism, given the differences in bioavailability of different generic alternatives.

Using clinician-focused nudges to improve health can be an effective strategy,⁶ but let’s come back to the original premise of the approach by Kaboli et al²—to improve patient outcomes by increasing patient activation. Improving patient activation is a good idea, as one of the central challenges for health care clinicians and health plans is getting patients engaged. A central reason for this may be that clinicians generally focus on achieving the clinician’s goals and not goals specified by their patients—clinicians typically do not invest the time to be trained on how to elicit patient goals and many either do not assess them at all or do not do this well. Getting patients to become more activated will likely require clinicians to both help patients achieve their own goals and create more patient-friendly environments in which patients feel empowered to communicate their goals and feel supported in their efforts to achieve them.

Financial incentives have been used widely by health plans and employers to increase engagement and to achieve higher rates of healthy behaviors, including a significant increase in smoking cessation rates,^7,8 but incentives to patients in health delivery system contexts have not been widely embraced. This is despite the fact that clinician incentives to improve outcomes are fairly common. A previous trial found that shared physician and patient incentives were more effective in improving cholesterol control than either patient or clinician incentives alone.⁹ Perhaps greater proof of efficacy will increase interest in this approach—and perhaps this will change as health delivery systems increasingly take on financial risk for populations of patients and prioritize increasing use of cost-effective services and improving health behaviors. In any case, nonfinancial strategies that make it easier to activate and preserve high levels of activation for patients such as encouraging enrollments in automated refills¹⁰ have the advantage that once a patient has signed up inertia works in favor of actions that improve health, whereas letters that rely on activation require a lot of ongoing effort to sustain. Financial incentives could be used to encourage enrollment in such programs.

Activating patients to improve outcomes requires maintenance of those behaviors longer term. Given the inherent challenges involved in either clinicians or patients exerting effort on an ongoing basis, the more we can design systems that make the healthy path the path of least resistance, the more likely such approaches will be to have sustained effects on patient and clinician behavior and patient outcomes.

Published: December 14, 2018. doi:10.1001/jamanetworkopen.2018.5011

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Volpp KG. JAMA Network Open.

Corresponding Author: Kevin G. Volpp, MD, PhD, Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, 1120 Blockley Hall, Philadelphia, PA 19104-6021 (volpp70@wharton.upenn.edu).

Conflict of Interest Disclosures: Dr Volpp is a principal in the behavioral economics consulting firm VAL Health and reported receiving funding from CVS, Vitality/Discovery, Hawaii Medical Services Association, Humana, Oscar, and Weight Watchers. None of these were directly related to this article.