As emergency physicians, we write prescriptions for patients that we discharge home for all manner of presenting complaints. I used to believe that the overwhelming majority of these prescriptions would be filled by the patient after discharge.
It turns out I was wrong.
Research estimates that patients discharged from emergency departments (EDs) fail to pick up their high urgency prescriptions, like antibiotics, nearly 35 percent of the time.
This is problematic because failure to fill high urgency prescriptions has been shown to lead to systemic waste and high individual morbidity, evidenced by higher infection-related rehospitalizations and all-cause rehospitalizations.
So why the low numbers?
The popular belief among experts holds that this discrepancy is mostly due to medication access and affordability constraints, but this may not be the full story.
Consider that, even in Massachusetts, where overall insured rates edge closer to 100 percent and access to care is higher than in most states, the number of failed prescription pick-ups mirrors the rest of the nation. In fact, a recent study among pediatric patients in a Boston emergency department found that 32 percent of families did not fill prescriptions for their child after a pediatric ED visit.
Moreover, that same study found no association between low health literacy, access to a primary care doctor, or affordability of the prescription, on whether or not a family would pick up their child’s prescription.
So to what can we attribute the discrepancy?
Part of the answer may come from the field of behavioral economics.
At discharge, most patients fully intend to pick up their prescription, but in practice, many never follow through and make it to the pharmacy. Researchers in behavioral economics who study the science of decision-making call this scenario an action-intention gap.
EDs may be able to do a better job of helping our patients follow through and close these action-intention gaps by adopting strategies from the unlikeliest of places, presidential campaigns.
In that scenario, many potential voters who fully intend to vote never follow through and make it to the voting booth on election day. Campaign strategists have leveraged insights from behavioral economics to close that action-intention gap and increase voter turnout in their candidate’s favor.
In 2008, behavioral economist and Harvard Kennedy School professor, Todd Rogers, set out to test novel interventions focused on increasing voter turnout during the 2008 Democratic Presidential Primary.
His team added an intervention to phone call scripts which were to be read to over 280,000 potential voters by campaign volunteers during standard get out the vote house calls. The call scripts contained messaging designed to remind potential voters about the election and their duty to vote.
To this standard script, his team added a simple but powerful behavioral economics intervention called an implementation intention which consisted of three follow-up questions designed to facilitate voting plan making: what time they would vote, where they would be coming from, and what they would be doing beforehand.
Implementation intentions work because we create a cognitive link between an anticipated future situation and the intended behavior by articulating the when, where, and how of following through on an intention. In other words, our plan for following through on a future behavior takes the form “if situation Y, then trigger behavior X.”
By creating this link upfront, we can increase the probability that we will follow through on that action.
Figure 1 provides an example of a nudge. A nudge is a concept in behavioral economics which influences an individual’s decision-making in a predictable way by leveraging subconscious processes and without forbidding any options or significantly changing their economic incentives.
Rogers found that by adding this costless nudge to the pre-existing script, his team was able to increase voter turnout by 4.1 percent over the control. To put this effect size into context, in the 2012 presidential election increasing voter turnout among eligible voters by just half that amount for one candidate’s supporters would have changed the outcomes in Florida, Ohio, and North Carolina.
Building on these findings, in the 2010 general election, his team tested another nudge called a threat of accountability, which holds that by subtly reminding an individual that they may be held accountable for following through on a future action, they will be more likely to follow through on that action. By adding the phrase, “We may call you after the election to talk about your voting experience,” to a piece of standard voter mailing they were able to increase the effectiveness of the mailing in terms of the voting it stimulated by almost half.
Both of these strategies have now become common staples of modern-day campaigns and are being implemented in the 2016 presidential primary race by candidates across the political spectrum.
How could this be applied to help increase prescription pick-up rates?
Imagine, as part of the discharge process, patients were asked a similar battery of questions: What time they will pick up their medication, where they will be beforehand, and how they will get there. This research shows that by weaving simple but validated nudges like this and a threat of accountability into pre-existing practices like patient discharge summaries, EDs may be able to help patients close the action-intention gap and follow through to pick up the medications we prescribe them at zero marginal cost.
The intersection of emergency medicine and behavioral economics is rich terrain for exploration and nudging may yet be the tool that helps us design and integrate a model of care that works best for our patients.
Alister Martin is an emergency medicine resident.
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