Karen Appold

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A physical nudge is not a push or shove, but a gentle prod (often with the well-placed elbow) to pay attention, to wake up, to look over there.

But today we are enveloped in a swarm of behavioral nudges, partly because we are riveted to our electronic devices. Amazon’s Alexa and Apple’s Siri ping us appointment reminders, tell us when to take the meal out of the oven, and prepare us to take that upcoming left turn at the light.

Nudges—and the technologies to deliver them—are becoming an increasingly important part of American healthcare. They are being used to keep patients safe, steer doctors and consumers to make more cost-effective decisions, and improve the quality of care. The trick to nudges, say experts, is for them to be not too controlling while putting people on a path to the “best” choice. Behavioral nudges, which can include setting defaults and digital reminders to offer chances at small financial rewards, need to anticipate innate flaws in human thinking that tend to overvalue immediate rewards and misjudge probabilistic scenarios.

The behavioral nudge is a concept from the field of behavioral economics. In 2017, Richard Thaler won the Nobel Memorial Prize in Economics for his work on behavioral economics, a field that combines economics with the psychology of making decisions. Nudges don’t restrict or force a choice or involve strong monetary incentives but instead help guide a stakeholder to a preferred option, says Mitesh Patel, M.D., MBA, director of the Penn Medicine Nudge Unit, which claims to be the first behavioral “design team” embedded in health system.

In healthcare, nudges originated out of a desire to improve patient safety; among the first nudges were notifications about allergies and adverse reactions to medications. “If a provider tried to order a medication and a patient had a documented allergy or adverse reaction to it, a pop-up would stop the physician and require them to either change the order or give a valid reason why they still wanted to order it,” says Joyce Brown, B.S.N., RN, the clinical informatics coordinator at Deborah Heart and Lung Center, a hospital specializing in cardiovascular and lung disease in southern New Jersey.

Nudging has branched out from there partly because the electronic health record (EHR) makes it relatively easy to use defaults and reminders to guide healthcare decisions. Patient portals and conversations between patients and clinicians also present chances for nudges to take place.

“There are opportunities to work through all of these mediums to align nudges with improved medical decision-making,” Patel says.

Patel and his colleagues at the Penn Medicine Nudge Unit have worked with clinicians from more than a dozen specialties to implement nudges in healthcare. The unit’s success stories include changing default settings in the EHR to increase generic prescribing from 75% to 98%, increasing referrals to cardiac rehabilitation for heart attack patients from 15% to 85%, and decreasing unnecessary imaging among patients with cancer at the end of their life from 68% to 32%. They have also used active choice prompts to remind clinicians to address gaps in care which have increased influenza vaccination, cancer screening and statin prescribing.

Physicians at Deborah Heart and Lung use nudges as reminders of best practices. “They are a way to provide guidance, but ultimately physicians make the decision for the type of care delivered,” Brown says.

Nudges can be used to help providers follow guidelines set by CMS, other government entities, and other organizations. Brown says that if certain protocols are required or recommended, nudges can increase the number of clinicians who follow them. If certain protocols are required that involve a number of tests, medications, or treatments, physicians can order all of them at the same time, Brown says.

Because nudges can be very powerful, they need to be implemented carefully. “We focus on driving outcomes using national guidelines and evidence-based criteria,” Patel says. “They are most useful when a specific decision point can be targeted to significantly shift decision-making behavior.”

Poorly designed nudges that seem coercive or counterproductive can backfire. Nudges should be designed to create a path of least resistance around a choice so that whoever is being nudged will be receptive to it, experts say. “Nudges can be made difficult to opt out of to increase the likelihood of behavior change, but it is important that a nudge actually aligns with what the people being nudged would see as either in their or society’s best interests,” says Kevin Volpp, M.D., Ph.D., director of the Penn Center for Health Incentives and Behavioral Economics and one of the world’s foremost experts on nudges and behavioral economics in healthcare.

“Well-designed nudges based on clinical evidence make it easier for clinicians to effectively treat patients based on the latest evidence,” Volpp says. “This can save time while also increasing the effectiveness and value of their care.”

But as with any other strategy or tactic designed to influence behavior, nudges can be overdone. In the realm of patient safety, “alarm fatigue” can set in so that safety alerts end up having the opposite of their intended effect because clinicians tune them out. “If a physician receives too many alerts, they may lose their importance,” Brown says.

At the University of Pennsylvania, raising generic prescribing rates by using nudges is considered one of the big behavioral economics success stories because it saved the health system about $32 million in the two and a half years after it was implemented.

“Before the prescribing default was changed to generic medications, clinicians weren’t opposed to prescribing generics, but they were unlikely to take the time to sift through a long list of alternatives to find one,” Volpp says. “Making it easy for clinicians to prescribe generics created a pathway whereby nearly 100% of clinicians now prescribe them.” Volpp says setting generics as a default is a good example of how making the optimum choice easier can guide people to a choice they might have made by themselves had they had more time to consider the decision.

Brown cites Deborah Heart and Lung Center’s sepsis program as one of its greatest successes with nudges. The hospital created a sepsis surveillance board that identified patients with early signs of sepsis. “If they truly show signs of sepsis, we have protocols that include CMS guidelines for sepsis care including timing of labs, fluids, and medications, and electronic documents to prompt the physician with what needs to be charted in order to meet regulations,” Brown said. She believes the program has been successful because physicians have everything they need at their fingertips.

Nudges have their limitations. Volpp says behavior change is unlikely to happen if there are strong financial incentives to stick with the status quo or to make a different change. “Nudges can have a significant influence on what patients and physicians do, but it’s difficult for nudges to overcome strong monetary incentives that induce behaviors,” Volpp says. 

If, for example, a clinician is compensated primarily for doing procedures, nudges to do fewer procedures are unlikely to have sufficient power to offset the compensation. In contrast, nudges can be highly effective for, say, decreasing antibiotic prescribing rates if there isn’t any countervailing incentive driving that behavior.

Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.

Articles

Applying lessons from behavioral economics, health systems are using “nudges” to influence the choices clinicians make.

No Pushing, no Shoving. Instead, Nudges in the Right Direction

Although there isn’t a cure for breast cancer, more effective treatments continue to emerge. Here’s a look at five developments for breast cancer treatment in the last two years.

Trodelvy (sacituzumab govitecan-hzly) was approved by the FDA in April to treat metastatic triple-negative breast cancer. It is called triple-negative because the cancer cells lack estrogen and progesterone receptors and the human epidermal growth factor receptor 2 (HER2) protein. Roughly 15% of breast cancers are triple-negative breast cancers, and they are more commonly diagnosed in women younger than 40. Triple-negative breast cancer is aggressive and is more likely to be diagnosed at a later stage than breast cancers with the receptors it lacks.

Trodelvy, which is administered intravenously, was approved to treat metastatic triple-negative breast cancer that has not responded to standard chemotherapy. The drug is an antibody-drug conjugate, which works like a smart bomb, says David Riseberg, M.D., chief of medical oncology and hematology at Mercy Medical Center in Baltimore. Antibody-drug conjugates are agents that combine antibodies and chemotherapy agents. With Trodelvy, it is the antibody’s job to recognize the trophoblast cell-surface antigen 2 — Trop-2, for short — receptor on the surface of triple-negative breast cancer cells. When that happens, it delivers a topoisomerase inhibitor that is toxic to the cancer cell. This approach of pairing recognition with a chemotherapy agent means the treatment is more precisely directed than chemotherapy alone.

In the ASCENT study that led to Trodelvy’s approval, a third of patients responded to the treatment as measured by overall response rate. “This is generally better than what would be expected in patients with triple-negative breast cancer who were previously treated with prior chemotherapy agents,” says Shannon Puhalla, M.D., a medical oncologist at the UPMC Hillman Cancer Center in Pittsburgh. However, Trodelvy was approved with a boxed warning about severe neutropenia and diarrhea. The commercial prospects for Trodelvy—and the antibody-drug conjugates in general— are bright judging by Gilead’s recent $21 billion acquisition of Immunomedics, the company that developed Trodelvy.

Enhertu (fam-trastuzumab deruxtecan-nxki) is another antibody-drug conjugate. Trodelvy and Enhertu show that drug developers believe there is a lot of promise in the find-and-treat approach of the antibody-drug conjugates. The FDA approved Enhertu in late 2019 as therapy as for metastatic HER2-positive breast cancer among patients who have been previously treated with two or more other types of treatments. With Enhertu, trastuzumab recognizes the cancer cell and the deruxtecan portion causes DNA damage in cancer cells that kills them off. Trastuzumab, a monoclonal antibody, ushered in the current era of cancer treatment that depends on agents that disable molecular-level pathways that feed cancer growth and spread. It was approved more than two decades ago, in 1998, and is sold under the brand name Herceptin, although there are now a number of biosimilars on the market: Herzuma, Trazimera, Kanjinti, and Ogivri.

Enhertu is administered intravenously and is usually given through a subcutaneous port, which allows for direct access to a large chest vein, says Hadeel Assad, M.D., a medical oncologist at the Karmanos Cancer Institute in Detroit.

“The treatment (Enhertu) offers a much-needed advancement in treating HER-2 positive breast cancers,” says Jonathan S. Goldberg, M.D., medical oncologist at CareMount Medical in Mount Kisco, New York, and medical director of cancer clinical trials at Northern Westchester Hospital. Although the drug is more expensive than standard chemotherapies used in later lines of therapy, it shows much better efficacy than the alternatives, in the opinion of Stavroula Otis, M.D., a hematologist and oncologist in Santa Ana, California. She believes the drug will delay complications that lead to hospitalizations, radiation therapy, chemotherapy, and surgeries by more than one year. However, Enhertu has a boxed warning about interstitial lung disease and pneumonitis, and in a pooled analysis of 234 patients, fatalities because of adverse reactions occurred in 4.3% of patients.

Balixafortide is a biologic therapy that blocks CXCR4, a protein found on the surface of many types of cancer cells. CXCR4 allows tumor cells to spread to other body parts, explains Peter Kaufman, M.D., an oncologist at the University of Vermont Medical Center in Burlington, Vermont. The FDA granted balixafortide fast-track status in 2018, and this summer Kaufman and a team of investigators presented positive findings for the drug at the annual meeting of the American Society of Clinical Oncology. Results from the phase 1 trial that enrolled 56 women with metastatic breast cancer that had been treated previously showed a greater response from a combination of balixafortide and eribulin, a chemotherapeutic agent sold under the brand name Halaven, than eribulin alone.

Balixafortide, which is being tested and developed by Polyphor, a Swiss biotech company, is being evaluated in a phase 3 study of close to 400 patients with HER2 negative metastatic breast cancer. “If similar results are reproduced in this study, it may be enough to seek regulatory approval without conducting more studies,” says Kaufman.

Women with breast cancer are frequently treated with between 15 and 20 radiation treatments over a three- or four-week period after breast-conserving surgery. New research suggests that fewer treatments over just a week’s time may be needed. Results from the FAST-Forward trial published in 

this year showed that five treatments were non-inferior to 15, notes Sushil Beriwal, MD, deputy director of radiation services at the University of Pittsburgh Hillman Cancer Center. Fewer treatments are less expensive and time-consuming for patients and sometimes there’s a lower chance of adverse effects.

A CT scan is used to map the target for radiation. Then, radiation oncologists mark the tumor’s boundaries and determine the necessary dosage using sophisticated computer programs, Beriwal says. This enables them to administer the radiation with a high level of accuracy. The patient is positioned on a treatment table and images or scans are taken before each treatment to make sure the radiation beams are targeted to the desired area.

Targeted intraoperative radiation therapy

Targeted intraoperative radiation therapy (TARGIT-IORT) is given in the operating room at the time of a patient’s initial lumpectomy to remove local breast cancer, says Valery Uhl, MD, a radiation oncologist in Northern California and president of the board of TARGIT Collaborative Group (TCG) in Sacramento, California. TARGIT-IORT consists of a single, highly precise dose of radiation given directly to the area where breast cancer was surgically removed. “This is ideal for patients with small breast cancers who choose lumpectomy as a treatment,” says Roshni Rao, M.D., chief of the breast surgery program at NewYork-Presbyterian Hospital in New York. “The treatment involves having a breast cancer surgeon remove the cancer from the breast, along with a small area of normal tissue around the edges. It decreases the side effects to the skin and allows patients to recover promptly.”

Intraoperative treatment radiation therapy has been used for many years, and results of a study with more than eight years of follow-up were published in 

 in August. They showed that intraoperative treatment was just effective as the more traditional adjuvant therapy.

The risk of cancer returning within the breast is less than 3% with intraoperative radiation, says Rao, and it’s less costly and more convenient for patients because it eliminates the need for follow-up visits for radiation.

“If the United States embraced TARGIT-IORT, the healthcare system would save millions,” says Uhl. “There are also advantages for the patient, such as convenience, reduced travel and personal costs, improved quality of life, and fewer side effects.” 

Two newly approved antibody-drug conjugates and changes in radiation therapy lead the way.

Five Important Advances in Breast Cancer Treatment

Jennifer Tryon, Pharm.D., M.S., FASHP, associate vice president and chief pharmacy officer, Wake Forest Baptist Health, Winston-Salem, North Carolina; residency program director for the Health System Pharmacy Administration and Leadership Residency Program

I grew up in Western Europe and came to the United States when I was 18 to pursue a pharmacy degree from the University of Iowa and a master’s of science from the University of Wisconsin. I went on to complete a two-year administrative residency at University of Wisconsin Hospitals and Clinics.

I took a job as the assistant director at Oregon Health & Sciences University and then became the assistant director of pharmacy and residency program director at PeaceHealth Southwest Medical Center in Vancouver, Washington. I also served as the chief pharmacy officer at the University of Chicago Medical Center and as the director of graduate pharmacy education there.

When I was growing up, my parents introduced me to the importance of having a liberal arts approach to life. I had a passion for leadership and helping others and an interest in the arts and sciences. I sought a profession where I could apply my diverse interests in service to others. The pharmacy profession allows me to work with talented teammates on innovative models of care, with a focus on improving services to our communities.

What has been your biggest learning experience in the industry? What did it teach you?

I’ve learned the importance of teamwork and collaboration in achieving success. Collectively, we can leverage our different skill sets, ideas and energy to create services that would otherwise not have been possible.

How has COVID-19 affected your responsibilities and how your organization operates? How might your job and your organization change because of the pandemic?

COVID-19 has impacted the manner in which our teams interact, especially as it pertains to introducing virtual platforms. There is a silver lining that the pandemic has afforded our organization in that we have ensured patient access to pharmacy services by leveraging telehealth platforms, expanding our population health platforms for community outreach to high risk patients, and introducing drone delivery of medications and equipment. I am proud to work for an organization that fosters innovation in care models.

How has the current discussion of racism and healthcare inequity affected you, your outlook and your organization? What has been the short-term response, and what do you envision happening over the longer term to your organization and American healthcare?

In the short term, we are creating awareness by providing forums to learn about racial inequalities and share our thoughts and emotions. The challenge I see before us is how we can move from awareness to actions aimed at decreasing racial disparities and ensuring all patients have the essentials; for example, housing, food and healthcare. This movement requires leadership and a commitment to study and address gaps in how we care for those we serve.

We cannot deliver on our mission of patient-centered care if we aren’t addressing racism and the impact of race on healthcare. This begins with an understanding of the health inequities specific to the Black community served by our health system so we can work to address them. As leaders and healthcare professionals, we are in positions of incredible influence in our community, and we have a responsibility to ensure that we leverage the opportunity to be and do better.

What other kinds of changes do you expect to see in healthcare in the next five to 10 years?

I expect to see medications become increasingly specialized and expensive. We need better methods to ensure affordability and access to care for patients. I also think healthcare will increasingly move to care in the home.

An area for healthcare to embrace is technology advancement and machine learning. This will present an opportunity to redeploy healthcare professionals to areas like primary care and geriatrics where patient needs are growing.

What have you enjoyed about social distancing and extra stay-at-home time during the past few months?

I have also enjoyed seeing my team flourish without us being together every day. It has been rewarding to see great progress even though we were working remotely.

Managed Healthcare Executive's October issue headlines 10 healthcare leaders in its fourth annual "10 Emerging Industry Leaders" feature. MHE spotlights each leader individually with a Q&A interview between MHE and the emerging leader.



10 Emerging Industry Leaders: Jennifer Tryon

Efrain Talamantes, M.D., MBA, MSHPM, chief operating officer, AltaMed Health Services,
Los Angeles

I grew up as the oldest of three children in Norwalk, California. My parents were raised in a rural farming community in Jalisco, Mexico, and immigrated to the United States in search of a better future. From poverty to lack of access to healthcare, the many experiences we faced as immigrants shaped my passion to improve others’ health and well-being. I credit my family, friends, teachers, mentors and outreach programs that recognized my potential and never allowed me to give up.

I earned a B.S. in psychobiology at UCLA, an M.D. at David Geffen School of Medicine at UCLA, an MBA at Emory University, and an M.S. in health policy and management at the UCLA Fielding School of Public Health. Next, I had a residency at the University of California, Davis (UC Davis). I also completed the prestigious Robert Wood Johnson Foundation Clinical Scholars Program at UCLA and was recognized by the Society of General Internal Medicine with the Mack Lipkin Sr. Associate Award for my research, “Community College Pathways: Improving the U.S. Physician Workforce Pipeline.”

After my fellowship, I served as the inaugural medical director for the hospital medicine department, and I helped open Martin Luther King Jr. Community Hospital in Los Angeles. I then served as the associate director for the UC Davis Center for Reducing Health Disparities and co-directed the Center for a Diverse Healthcare Workforce.

Today, I serve on the executive physician leadership team at AltaMed and as the medical director for the AltaMed Institute for Health Equity, leading research, innovative health delivery, and training programs that address disparities affecting our patients. Under my leadership, AltaMed received its first Patient-Centered Outcomes Research Institute grant to develop the Health Equity to Advance Latino Patient-Centered Research community advisory board. I also serve as the designated institutional officer for AltaMed’s inaugural family medicine residency program.

My interest in medicine was fueled by interpreting for my parents in the hospital. I experienced how cultural and language barriers impact quality of care. I combined my passion for science and serving my community by pursuing medicine with the help of mentors and my family.

The healthcare industry has trailed behind in embracing people of color in leadership. I’ve learned that my patients and colleagues benefit from my partnership in solving some of today’s most pressing challenges. If we co-design our healthcare delivery system with underrepresented groups in mind, we can improve the health of those who suffer most. I also dedicate a lot of time to mentoring students who come from underrepresented backgrounds.

Thepandemic has shown how fragmented our system is when serving theunderinsured. During the pandemic, AltaMed re-imagined healthcare by providing access to COVID-19 testing in underserved communities, scaled access to telehealth and invested in our workforce’s well-being.

We held a town hall for 8:46 minutes in remembrance, where many of us kneeled for George Floyd and Black lives lost to violence. We held a panel discussing AltaMed’s position on law enforcement violence and racism as a public health crisis. We’re working on anti-racism initiatives to improve health outcomes for people of color.

What other kinds of changes do you expect to see in healthcare in the next 5 to 10 years?

I expect to see us find better ways to care for people in their homes using technology. My goal is to ensure that access to these programs will be equitable. I also expect to see health equity play a more central role in how we design healthcare delivery.

I’ve had the chance to rediscover how fun it is to play hide-and-seek with my children and how important these straightforward games are to bonding. I have yet to find the best hiding place in our home, as my daughter always finds me and my son.

Managed Healthcare Executive's October issue headlines 10 healthcare leaders in its fourth annual "10 Emerging Industry Leaders" feature. MHE spotlights each leader individually with a video interview to accompany the Q&A between MHE and the emerging leader.



Karen Appold

Articles

No Pushing, no Shoving. Instead, Nudges in the Right Direction

Five Important Advances in Breast Cancer Treatment

10 Emerging Industry Leaders: Jennifer Tryon

10 Emerging Industry Leaders: Efrain Talamantes