The limits of behavioural economics in medicine

In general, it work betters in public health than in more direct health care

Whenever I talk to physicians about outcomes that are worse than you’d expect, they are quick to point out that non-compliance — when a patient does not follow a course of treatment — is a major problem.

Sometimes prescriptions aren’t filled. Other times they are, but patients don’t take the drugs as prescribed. All of this can lead to more than 100,000 deaths a year.

A thorough review published in The New England Journal of Medicine about a decade ago estimated that up to two-thirds of medication-related hospital admissions in the US were because of non-compliance, at a cost of about $100 billion a year. These included treatments for HIV, high blood pressure, mental health and childhood illnesses (it can be difficult to get children to take their medicine, too).

To address the issue, researchers have been trying various strategies, including those rooted in behavioural economics. So far, there hasn’t been much progress. A systematic review published five years ago in Annals of Internal Medicine looked at all kinds of trials that tried to improve patient compliance. It found some limited successes in improving patient compliance in different disorders, but most of the trials were small and not easily generalised outside the research setting.

A more recent Cochrane review concluded that “current methods of improving medication adherence for chronic health problems are mostly complex and not very effective”.

At first glance, behavioural economics — the basis of Richard Thaler’s recent Nobel Prize in Economics — seems like a rich field of potential solutions. People tend to do things, like donate organs, when it’s the default option as opposed to something they need to request. They tend to be less likely to miss appointments if you tell them how many other patients show up for theirs. They tend to be more likely to engage in preventive behaviours like using sunscreen if you focus on the benefits, not harms. Many are turning to ideas like these to improve medication adherence.

But those excited about the potential of behavioural economics should keep in mind the results of a recent study. It pulled out all the stops in trying to get patients who had a heart attack to be more compliant in taking their medication. (Patients’ adherence at such a time is surprisingly low, even though it makes a big difference in outcomes, so this is a major problem.)

Researchers randomly assigned more than 1,500 people to one of two groups. All had recently had heart attacks. One group received the usual care. The other received special electronic pill bottles that monitored patients’ use of medication. Those patients who took their drugs were entered into a lottery in which they had a 20 per cent chance to receive $5 and a one per cent chance to win $50 every day for a year.

That’s not all. The lottery group members could also sign up to have a friend or family member automatically be notified if they didn’t take their pills so that they could receive social support. They were given access to special social work resources. There was even a staff engagement adviser whose duty was providing close monitoring and feedback, and who would remind patients about the importance of adherence.

This was a kitchen-sink approach. It involved direct financial incentives, social support nudges, health care system resources and significant clinical management. It failed. The time to first hospitalisation for a cardiovascular problem or death was the same between the two groups. The time to any hospitalisation and the number of hospitalisations were the same. So were the medical costs. Even medication adherence — the process measure that might influence these outcomes — was no different.

The researchers in this trial deserve praise for their frank assessment of their results, as well as for trying to brainstorm ways in which they might achieve success in the future. Getting patients to change their behaviour is very hard. In the past, we’ve tried making drugs free to patients to get them to adhere to their medications and improve outcomes. That failed. We’ve tried lotteries (as in the study above) to nudge people to achieve better compliance. That failed.

Maybe financial incentives, and behavioural economics in general, work better in public health than in more direct health care.

© 2017 The New York Times