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Everyday Life Politics and Public Policy

Defaults: the role of the status quo in healthcare solutions

Defaults are simple, affordable, and cost-efficient solutions which can be introduced in order to elicit the desired behaviour by individuals. They are one of the most intuitive mechanisms implemented in choice architecture, and their use can be applied to a range of different choice-making settings, as they simply leverage on the assumption that individuals are disproportionately more likely to stick to the option presented to them rather than actively switching to an alternative. The default is hence defined as the automatic option, representing the outcome which will take place in case individuals do not make a proactive decision. But why do people tend to stick to the default? One reason could be compliance to what is perceived as being the social norm, another the tendency to postpone complex choices, or even the unawareness of the possibility to actively change the default. Moreover, people reasonably tend to assume that the default has been set as a consequence of an informed decision, a perspective which makes change undesirable. Overall, people often incur in a loss adverse behaviour which makes them reluctant to diverge from what they perceive to be the baseline option, often because they are not certain of what such decision entails, or because they are not able to independently make an informed decision for themselves.  

Defaults are a valuable instrument to be used by decision makers and managers for a range of scopes, but one possible application which has been demonstrated to be particularly effective is that of using defaults to shape healthcare outcomes. Indeed, introducing efficient and effective baseline options can improve the management of resources in the sector by successfully nudging both healthcare professionals and healthcare service recipients towards the best option available. Of course, setting the default option entails a responsibility which should not be ignored, but, if used strategically, it can offer the possibility of significantly improving public health, as demonstrated by the instances below. 

The impact of defaults on pharmaceutical prescriptions 

The over prescription of pharmaceutical drugs can have severe adverse effects on public health, as it has been the case for the opioid crisis related to the misuse and abuse of pharmaceutical opioid drugs. It can be argued that the excessive reliance on prescription opioids for postprocedural pain has been a contributing factor to the opioid endemic and, indeed, recent US data shows that opioids make up more than one-third of surgeons prescriptions, and that amounts prescribed tend to exceed the quantities actually needed by most patients. As a consequence, access to excessive amounts of opioids can lead to adverse consequences such as addiction, pharmaceutical drugs abuse, and even unintentional overdoses. In order to address this issue, an experimental study by Chiu at. al (2018) has leveraged on the reliance of surgeons on electronic medical records in filling their prescriptions. By lowering from 30 to 12 the default number of opioid pills prescribed for after-surgery analgesia in the electronic system, it was possible to achieve a decrease of 15% in prescriptions. This proved to be a simple and effective solution, which could be potentially scaled to contain medication costs and, most importantly, to overcome the adverse effects of over prescription on patients.  

Do defaults save lives?  

Do defaults save lives? This is the question posed by Johnson and Goldstein (2003) in their seminal study on the impact of default options on the percentages of organ donors present in different countries. The short answer is yes, they do. Their analysis concerns the effective rates of consent to organ donation, and they observe that, although surveys results show an average consent to donation of around 80 percent across almost all countries, the actual proportion of individuals registered in organ donor registers is actually very different among states. This proportion is in fact impacted by the default option provided for in the country’s legislation, depending on whether an opt-in system (requiring explicit consent) or an opt-out system (considering presumed consent) is in place, with the latter effectively achieving much higher rates of consent. The effect of the default option in this case is extremely sizeable, and the authors predict that changes in defaults could increase donations by thousands each year. Moreover, as each donor can contribute to more than one transplant, defaults can possibly have an exponential impact in terms of number of lives saved.  

Defaults and healthcare staff’s compliance with guidelines 

The presence of inefficient defaults can be extremely burdensome for public organizations in general, but especially for hospitals, where timeliness and precisions are essential. This issue becomes even more important in light of the strong reliance of healthcare professionals and healthcare staff on defaults options. To demonstrate the impact of correct and incorrect default options on the practices and compliance to guidelines of hospital professionals, a study by Bellé et al. (2020) focused on testing the correct use of surgical gloves. The authors ran a randomized control trials on healthcare professionals working in public health care organizations, asking the control group to select from a list the correct answers concerning the correct use of gloves, and asking instead the treatment group to find the incorrect options from the same list, but among the answers which they found already pre-selected. In this case, due to the impact of defaults, the treatment group significantly underperformed. Results are even more significant when considering that the experiment concerned something as easy as the correct use of gloves, an item with which every healthcare professional works on a daily base.   

Conclusion

It is possible to argue that the use of default is a powerful nudging mechanism which should be employed in healthcare management to improve health outcomes and insure a better performance in hospitals. There are many more instances of the possible applications of defaults in healthcare but, given the sensible nature of health decisions, it is imperative that they are applied with objective reference to scientific finding on what is best for patients.  

Sources:

Bicket M.C., Long J.J., Pronovost P.J., Alexander G.C., Wu C.L. Prescription opioid analgesics commonly unused after surgery: a systematic review. JAMA Surg. 2017;152(11): 1066-1071. 

Chiu, A. S., Jean, R. A., Hoag, J. R., Freedman-Weiss, M., Healy, J. M., & Pei, K. Y. (2018). Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing. JAMA Surgery, 153(11). 

Halpern, S. D., Ubel, P. A., & Asch, D. A. (2007). Harnessing the Power of Default Options to Improve Health Care. New England Journal of Medicine, 357(13), 1340–1344.  

Johnson, E. J. & Goldstein, D. G. (2003). Do Defaults Save Lives? Science, 302: 1338-1339. 

Levy. B., Paulozzi L., Mack K. A. & Jones C. M. (2015). Trends in opioid analgesic–prescribing rates by specialty, U.S., 2007-2012. Am J Prev Med, 49(3): 409-413.  

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