Evidence for Behavioural Nudge Interventions to Reduce Low-Value Care

Abstract

Low-value care, defined as tests and treatments that are of limited benefit, inappropriate, or harmful, poses a significant challenge to the quality, safety, and sustainability of healthcare systems worldwide. Traditional de-implementation strategies, such as educational campaigns, are resource intensive and have had limited success in reducing low-value care. Interventions informed by behavioural economics, commonly referred to as nudges, have therefore been proposed as a potentially scalable approach to reducing low-value care, although their effectiveness remains uncertain.

The primary aim of this thesis was to evaluate the evidence on the effectiveness of nudges in reducing low-value care. The thesis employed a range of methods, including a study within a trial, a systematic review, and randomised controlled trials, to evaluate behavioural economic nudge interventions aiming to improve patient and clinician decision-making and reduce low-value care. These methods were applied across healthcare settings including primary and emergency care settings.

This thesis provides robust evidence on both the potential for and limitations of nudges to reduce low value care. Nudges appear to be a feasible de-implementation strategy in routine settings, but their effects depend strongly on nudge type, intervention design, targeted behaviour, patient population, and clinical context. clinical context and intervention design. Nudge effects may be moderated by factors such as the costs of changing behaviour, perceived risks of harm from de-implementation, and the timing of consequences. As nudges become more widely used in healthcare, rigorous evaluation, monitoring of unintended effects, and inclusion of patient centred outcomes are essential.