Sunday, August 11, 2013

This land is your land (Musings on transfusion-related nudging)

Please return as blogs are always revised once published

Blog ideas often have strange origins. This month's blog was stimulated by an article in Canada's Macleans about UK politics:
The 'nudge' idea adopted by the British PM comes from
In the book Sunstein and Thaler delve into behavioral economics, research that combines economics and psychology. Such studies document how our apparently free choices are affected by the way options are presented to us, i.e., no decision setting is neutral.

Much of behavioral economics is common sense and many of us are aware when we're being manipulated (nudged) in right (or wrong) directions. For example, being

  • Asked at the checkout counter if you need a bag to carry a purchase (Oh, maybe not.)
  • Faced with junk food at checkout, instead of fresh fruit (Hmmm, that Cherry Blossom chocolate bar looks delicious. Haven't had it since I was a kid....)
The authors propose libertarian-paternalism, the union of 
  • Retaining freedom to make the choices we want (libertarianism)
  • Yet nudging us to make the 'right choices' for our own good (paternalism)
The main principle of nudging is that, although we often make choices against our best interests, if we are cleverly nudged in the right direction, but not forced to do so, we may very well do what 'choice architects' - intelligent, paternalistic 'big daddies' who plan, design, and frame our choices - want us to do.

Our decisions tend to be either automatic (rapid knee-jerk responses) or reflective (thinking about a choice). Nudging offers a context to choices that gets us to reflect before deciding.

Framing a nudge to motivate a 'right choice' is difficult and experiments are needed to determine which types of nudges work best for particular groups.

Note that nudging need not be annoying 'father knows best' stuff. Nudges can be fun, as shown by this


An example of a formal TM 'nudge' strategy is outlined in this 2007 blog: What's up doc? Welcome to docovigilance

  • Dzik S. Use of a computer-assisted system for blood utilization review. Transfusion 2007;47(s2): 142S.
The author's hospital uses multiple blood utilization strategies, including a hospital transfusion committee, educational conferences for clinicians, wallet cards with reminders of transfusion guidelines, and more. But the paper focuses on

  • Computerized physician order entry (POE)
  • Computer-assisted blood utilization review and feedback
In brief, the system functions as follows:
  • All routine blood requests occur via POE software. 
  • Criteria for blood usage review are displayed on the computer screen at the time of the request. 
  • An unusual request triggers a pop-up window alerting the physician to a possible error in the order. 
  • For blood components, a reason for transfusion must be selected before the software will process the order.
  • A TM physician reviews the daily reports and physicians who made questionable decisions to transfuse are targeted for education (a nudge).
THE NUDGE: A non-judgmental e-mail is sent to the clinician within 24 hours of the decision to transfuse. The e-mail displays pre- and post-transfusion lab data, provides the criteria for the review process, and links to an in-house educational site.The e-mail invites the physician to reply if there are questions or concerns.

Many people are hard to nudge, including physicians. U
sing many strategies, transfusion service medical directors have long tried to nudge clinicians into adopting best practices and evidence-based guidelines (where they exist) with limited success. 

A major effort to nudge physicians to improve blood utilization and safe transfusion practices focuses on developing blood utilization guidelines followed by audits and feedback.

Some research includes making clinicians aware of how their transfusion practices compare to others. Such nudging borders on shaming, even though it's private, at least between nudgers and nudgees. Because docs think of themselves as leaders, not outliers, in theory such comparisons can nudge them into better behaviour.

Multiple problems exist with nudging physicians:

1. Docs don't like nudges. Historically, physicians were god-like heroes beyond questioning. Today, docs with god complexes are anachronisms but the notion that physician decisions shouldn't be questioned, even by colleagues and peers, remains.

Unless carefully and diplomatically framed, clinicians don't like unasked for advice by lab doc dudes / dudettes, who in the view of some clinicians, are removed and sheltered from brutal realities in the trenches.

Physicians especially do not like to be told what to do or have decisions questioned by other health professionals such as laboratory staff, nurses, and pharmacists. Granted that nudging involves suggesting, not dictating, but to a clinician even a nudge may resemble an order questioning their authority.

2. Formal nudging programs require devoted resources. And everywhere TM resources are increasingly scarce.

Automated nudges triggered by inappropriate transfusion orders, as described by Dzik, in theory require fewer resources than systems that rely solely on human interventions. But these too need significant resources to develop, maintain, and improve.

3. Nudges involving patient care need solid evidence, which doesn't always exist:

Tinmouth A, Thompson T, Arnold DM, Callum JL, Gagliardi K, Lauzon D, Owens W, Pinkerton P. Utilization of frozen plasma in Ontario: a provincewide audit reveals a high rate of inappropriate transfusions.Transfusion 2013 May 14. [Epub ahead of print]

  • Results: 28.6% of frozen plasma transfusions did not meet basic guidelines for appropriate transfusions
According to the lead author (Source: AABB News, July 2013, The role of patient-centered research in helping improve care, p. 15):
  • Results disappoint because they show little improvement over prior studies. Even in teaching hospitals with established guidelines, inappropriate use was ~ 20%.
  • Since guidelines rely on expert opinion, not evidence, to suggest when frozen plasma is beneficial, or even harmful, clinicians fear that, if they don't try to correct abnormal blood test results, bad outcomes may result.
My take: Seems that clinicians want to do something to help their patients even if there's no evidence it helps. And experts be damned.

In a way, such doc behaviour - automatic, unreflective gut reactions to do something, anything - reminds me of desperate patients who try quack treatments.

Regardless, nudging would be easier if more evidence existed for transfusion-related decisions.

Unfortunately, most formalized nudging programs have failed to achieve large improvements in clinical practice.

This Cochrane review found that feedback may be more effective when 

  • Baseline performance is low
  • Source is a supervisor or colleague
  • Provided more than once
  • Delivered in both verbal and written formats
  • Includes both explicit targets and an action plan 
In addition, the effect size varied based on the clinical behaviour targeted by the intervention. In other words, some behaviours are easier to change.

Main conclusions:
Audit and feedback generally leads to small but potentially important improvements in professional practice....Future studies of audit and feedback should directly compare different ways of providing feedback.

The 'piano stair' example above shows how nudging can be fun. The mind boggles at how transfusion professionals could be nudged into more effective practices with good humour, e.g.,  f
rom a Jan. 2011 blog, 'Tough Titty' and other iPad apps (Musing on 'revolutionary' apps for TM), Iggy, the IVIG app
In the future, perhaps we will have Iggy, an IVIG app available to clinicians on their iPads, iPhones, etc., which may even be networked to the hospital or regional health IS. When a doc orders IVIG via an electronic order system, the Iggy app would kick in. Can't you just see it?

Hey, dude, that's $10,000 and that's just for starters! Are you really, really sure the patient will benefit? What's the evidence? Read all about it here. Oh, and dude, you are the only one to order this product for this condition in this health region in the past year. In case you were wondering, this distinction is not good. Text or Skype and we can discuss.
Well, maybe that's more shaming than fun, at least to the nudgee. Darn!

Perhaps docs could be encouraged to better transfusion practice using a physician order entry that included an employer sanctioned ticket to play a video game with Playstation, Xbox or Wii U if their transfusion order was acceptable, e.g., 
  1. 'You're no transfusion donkey' wins chance to play Donkey Kong Country Returns 3D
  2. 'Saved money' gets you Sly Cooper: Thieves In Time 
  3. 'Won't kill the patient' wins Tomb Raider
Nudges don't need to be resource-draining, formalized mega-projects. We can all nudge someone each day in small ways without turning into nags.

Indeed, we regularly frame options to influence each other's decisions. Nudging is second nature.

This land is your land emphasizes how to nudge clinicians but all of us need regular nudges, inc. TM medical directors, medical laboratory technologists / scientists, nurses, pharmacists, administrators, policy makers, and last but not least, patients, our raison d'ĂȘtre.

Despite few resources, transfusion professionals should continue to develop nudging strategies to help clinical colleagues and each other become more knowledgeable about best transfusion practices to enhance patient safety.

Nudging works best if it's soft paternalism, i.e., suggests, not dictates, best practices so that colleagues are free to do what they want, yet become aware if they're outliers, and can reflect on future transfusion decisions.

Where possible, nudges should involve fun.

What resonates with me may not resonate with you. But one song that fits this blog was written by Woody Guthrie a whopping 73 years ago (1940) yet is sung by major artists to this day. It's become a cliche but still rings true.

This version is from the 'We Are One Concert' for Obama's inauguration as 44th U.S. President at Lincoln Memorial & National Mall in Washington, D.C. 2009, ~500,000 attending:

To me the song has a broad meaning relevant to all humans, including transfusion professionals. We are all in this together, nudgers and nudgees. No we, no they, just all of us making transfusion medicine better and safer. 

Get out there and nudge somebody. Opportunities abound.

As usual views are mine alone and comments are most welcome.