behavioral economics

Grand Rounds March 13, 2026: Behavioral Economics and Medication Adherence for Hypertension: A Randomized Clinical Trial (John A. Dodson, MD, MPH)

Posted on by Sophia Ramirez

Speaker

John A. Dodson, MD, MPH
Associate Professor of Medicine and Population Health
Director, Geriatric Cardiology Program
Director, Cardiovascular Digital Health Laboratory
NYU Langone Health
NYU Grossman School of Medicine

Keywords

Behavioral Economics; Cardiovascular Disease; Hypertension; Medication Adherence

Key Points

  • Roughly half of patients with cardiovascular disease (CVD) are nonadherent with their medications. This occurs across conditions and for multiple reasons, including cost, side effects, lack of symptoms, and inconvenience. BETTER-BP, a phase 2, multisite trial, sought to test the effect of a lottery on antihypertensive adherence. The lottery intervention was based in behavioral economics, a field that represents a novel and potentially scalable approach to improving medication adherence.
  • In a safety-net population, the lottery doubled adequate antihypertensive medication adherence from baseline to 6 months. This did not translate to a significant reduction in office-measured systolic blood pressure (BP) and increased adherence was not sustained after the lottery was removed. Other strategies will likely be required for long-term behavior change.
  • BETTER-BP had pragmatic components and non-pragmatic components. It was pragmatic in that it utilized minimal exclusion criteria; took place in a real-world setting; used existing medications; paired study visits with regular ambulatory visits; and used the electronic health record to ascertain some measures. It was not pragmatic in that it utilized traditional informed consent; the intervention and monitoring strategies were not usual practice; and the primary outcome was measured via an in-person BP assessment.

Discussion Themes

Dr. Dodson noted that many trials of behavioral economics in CVD medication adherence have not had durable effects on either adherence or clinical outcomes. Even with trials that are positive, no intervention has been a “home run.”

The lottery payouts (ranging from $5 to $50) were based on an estimated daily value intended to influence behavior without being coercive or exceeding study budgets.

Recruitment for the trial was a challenge; the team made approximately 9,000 phone calls to reach their final sample of 400 participants.

Behavioral incentives might be better suited for time-limited interventions, such as smoking cessation, rather than the lifelong management required for conditions like hypertension.

March 11, 2026: Behavioral Economics and Medication Adherence, in This Week’s Rethinking Clinical Trials Grand Rounds

Posted on by Sophia Ramirez

In this Friday’s Rethinking Clinical Trials Grand Rounds, John A. Dodson of NYU Langone Health will present “Behavioral Economics and Medication Adherence for Hypertension: A Randomized Clinical Trial.”

The Grand Rounds session will be held on Friday, March 13, 2026, at 1:00 pm eastern.

Dodson serves as the director of both the Geriatric Cardiology Program and the Cardiovascular Digital Health Laboratory at NYU Langone Health. He is an associate professor of medicine and population health at the NYU Grossman School of Medicine.

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Grand Rounds October 18, 2024: Rigorous Testing of Behavior Change Interventions: Lessons from the BE ACTIVE Randomized Clinical Trial (Alexander Fanaroff, MD, MHS)

Posted on by Sophia Ramirez

Speaker

Alexander Fanaroff, MD, MHS
Assistant Professor of Medicine
Perelman School of Medicine
University of Pennsylvania

Keywords

Gamification; Financial Incentives; Physical Activity; Behavioral Economics

Key Points

  • Observational studies have found an inverse association between steps per day and risk for all-cause mortality and cardiovascular events. Though national surveys indicate the vast majority of people believe that exercise has many health benefits, many don’t exercise.
  • Behavioral economics seeks to explain why people make the decisions they do using concepts from economics and psychology. Dr. Fanaroff discussed how known biases in decision making – immediacy bias, status quo bias, and the endowment effect – create a disconnect between the “planner” self and the “doer” self. This framework can be used to understand why people don’t exercise, even when they know they should.
  • Another barrier that the research team identified was that existing guidelines from the American College of Cardiology and American Heart Association lack specificity and strong supporting evidence. Dr. Fanaroff ultimately introduced an alternative recommendation based on their findings.
  • The research team sought to leverage our existing biases in order to facilitate a sustained increase in physical activity. In a randomized controlled trial, they compared the effectiveness of gamification, financial incentives, and a combination of the two on increasing physical activity over a 12-month intervention period and a 6-month follow-up period.
  • After noting a discrepancy between the proportion of Black patients in the target population and participant population, the research team adjusted their recruitment strategy until they had a representative group. While direct-to-patient recruitment avoids biases related to who physicians invite to clinical trials, it may introduce biases related to who trusts researchers enough to join a study.
  • The research team found that gamification and financial incentives were roughly equally effective, leading to about 500 more steps per day than the control group. The combination arm saw the biggest improvement, with about 850 more steps per day than the control group. In practice, gamification is the more scalable and inexpensive of the interventions.
  • If stakeholders are to pay for an intervention like this, large scale clinical trials are needed to show improvements in patient-centered outcomes or clinical events.

Discussion Themes

Pharmaceutical interventions are not expected to be effective once treatment has ceased. If a behavioral intervention is shown to be effective during the period in which it’s administered, should it be held to a standard of long-term sustainability?

Patients set their own step count goals according to their baseline when the trial started.

The components of the intervention guided by behavioral economic theory, i.e. the immediacy of the innovation, the loss (rather than gain) of cash and/or points, and the support partners, differentiates it from the gamification built in to many wearables and fitness trackers.

November 29, 2023: NIH Offers Methods Webinar on Implementation Science With Insights From Behavioral Economics

Posted on by Damon Seils

The NIH Office of Disease Prevention will continue its Methods: Mind the Gap webinar series on Friday, December 8, with "Supercharging Implementation Science With Insights From Behavioral Economics." Rinad Beidas, chair and Ralph Seal Paffenbarger Professor of Medical Social Sciences at the Feinberg School of Medicine at Northwestern University, will lead the webinar.

The Methods: Mind the Gap series explores research design, measurement, intervention, data analysis, and other methods of interest in prevention science. The December 8 session will describe efforts to use tools from implementation science and behavioral economics to improve implementation of evidence-based practices.

Register in advance to join the online presentation. Registration is required.

April 5, 2023: This Friday’s PCT Grand Rounds Highlights Applications of Behavioral and Implementation Science in Cardiovascular Medicine

Posted on by Damon Seils

Headshot of Dr. Srinath AdusumalliIn this Friday’s PCT Grand Rounds, Srinath Adusumalli of the University of Pennsylvania will present “A Nudge Towards Cardiovascular Health: Applications of Behavioral and Implementation Science in Cardiovascular Medicine.” The Grand Rounds session will be held on Friday, April 7, 2023, at 1:00 pm eastern.

Dr. Adusumalli is an adjunct assistant professor of medicine and an adjunct professor of healthcare management at the University of Pennsylvania. He is the senior medical director of enterprise virtual care and retail health for CVS Health, where he drives clinical initiatives to support the company’s virtual strategy.

Join the online meeting.

February 21, 2020: Nudge Study Updates (Michael Ho, MD, PhD; Sheana Bull, PhD, MPH)

Posted on by Gina Uhlenbrauck

Speakers

Michael Ho, MD, PhD
Professor of Medicine, University of Colorado School of Medicine
Staff Cardiologist, Rocky Mountain Regional VA Medical Center

Sheana Bull, PhD, MPH
Professor, Colorado School of Public Health
Director, mHealth Impact Laboratory

Topic

Nudge Study Updates

Keywords

Cardiovascular health; Behavioral nudges; Disease self-management; Pharmacy data; Text messaging; mHealth; Medication adherence; Choice architecture

Key Points

  • Up to 50% of patients do not take their cardiovascular medications as prescribed. Nonadherence is associated with increased cardiovascular events.
  • Nudges prompt small, incremental changes in behavior and can be delivered through text messaging.
  • The Nudge pragmatic study was piloted across 3 integrated healthcare systems. The intervention uses pharmacy data to monitor gaps in patients’ cardiovascular medication refills. Patients with gaps receive text messages on their mobile phone to remind them to refill their medication.

Discussion Themes

A “chatbot” is used in one of the study arms to interact with the patient through the mobile phone application. As part of the analytic plan, the study team will be evaluating engagement with the interactive chatbot and the dose response.

The Nudge study gives patients two opportunities to opt out of participating. The study team is tracking demographics of patients who opted out as well as their reasons for opting out.

How do you handle the roughly 10% of people who receive care from more than one health system? That is, patients may be receiving conflicting advice, including directions to discontinue their medications.

Learn more about the Nudge NIH Collaboratory Trial.

Tags
#pctGR, @Collaboratory1

February 7, 2020: Using Nudges to Improve the Delivery of Health Care (Mitesh S. Patel, MD, MBA)

Posted on by Gina Uhlenbrauck

Speaker

Mitesh S. Patel, MD, MBA
Ralph Muller Presidential Assistant Professor
Perelman School of Medicine & Wharton School
University of Pennsylvania
Director, Penn Medicine Nudge Unit

Topic

Using Nudges to Improve the Delivery of Health Care

Keywords

Motivational nudges; Medical decision-making; Behavioral economics; Nudge units; Health behaviors

Key Points

  • Nudges remind, guide, or motivate a decision. In a healthcare setting, medical nudges use principles of behavioral economics and psychology to “steer medical decision-making toward higher value and improved patient outcomes.”
  • A “nudge unit” is a behavioral design team that systematically tests ways to improve decisions and change behavior.
  • It is important that medical nudges be testable and rigorously evaluated. Well-designed nudges have the right fit for the context, are aligned with health system and patient care goals, are scalable, and make a significant impact.
  • Nudges can be used to help clinicians promote evidence-based care, and help patients increase engagement and change health behaviors.

Discussion Themes

Nudges are prevalent in other industries; for example, when asked to add trip insurance to the purchase of an airfare.

In a healthcare setting, effective nudges can help achieve care delivery priorities (for example, improved screening, follow up, adherence) as well as reduce clinician burden.

Understanding the health system’s culture and workflow is essential for the sustainability and effectiveness of nudges.

Read more about nudges in Using Nudges to Improve Value by Increasing Imaging-Based Cancer Screening (Patel et al, Journal of the American College of Radiology, 2019).

Tags
#pctGR, @Collaboratory1, @miteshspatel, @PennNudgeUnit

January 17, 2020: Assessment of the Human Systemic Absorption of Sunscreen Active Ingredients: FDA-Sponsored Randomized Clinical Trial (Murali Matta, MPharm, PhD)

Posted on by Gina Uhlenbrauck

Speaker

Murali Matta, MPharm, PhD
Bioanalytical Lead
Division of Applied Regulatory Science
Office of Clinical Pharmacology
Food and Drug Administration

Topic

Assessment of the Human Systemic Absorption of Sunscreen Active Ingredients: FDA-Sponsored Randomized Clinical Trial

Keywords

FDA; Sunscreen; Randomized controlled trial; Regulatory; Data analysis

Key Points

  • The active ingredients in nonprescription sunscreen products are organic chemicals, some of which have been shown to be absorbed through human skin with detectable levels in the blood or urine.
  • It is important that randomized clinical trials be conducted to better understand the clinical significance of systemic exposure to sunscreen products.
  • In this trial, all active ingredients in all tested products exhibited systemic exposures above the threshold for potentially waiving some nonclinical toxicology studies for sunscreens.

Discussion Themes

Do the observed differences in the sunscreen concentration depend on the application type; for example, spray versus lotion versus cream?

While additional toxicology data are needed, the results of this study do not indicate that individuals should refrain from the use of sunscreen.

Is there opportunity for collaboration with other organizations including private physician-scientists to conduct larger population studies with consumers?

Read more about Dr. Matta’s study at Shedding New Light on Sunscreen Absorption and in a recent JAMA publication.

Tags
#pctGR, @Collaboratory1, @US_FDA

January 10, 2020: Pragmatic Trials of Behavioral Economic Interventions to Increase Colorectal Cancer Screening (Shivan Mehta, MD, MBA)

Posted on by Gina Uhlenbrauck

Speaker

Shivan Mehta, MD, MBA
Assistant Professor of Medicine and Health Policy
University of Pennsylvania

Topic

Pragmatic Trials of Behavioral Economic Interventions to Increase Colorectal Cancer Screening

Keywords

Behavioral economics; Colorectal cancer; Pragmatic clinical trials; Health technology; Communication modality; Informed consent

Key Points

  • Colorectal cancer is the second leading cause of cancer deaths in the United States. Increased rates of screening can reduce mortality from colorectal cancer by 30% to 70%.
  • Use of behavioral economics can help us understand human motivation and behavior related to participating in clinical studies. How the message to patients is framed—and how choices are offered—can alter the response.
  • In the example pragmatic trial, the “choice architecture” for the colorectal cancer screening was designed by the study team in collaboration with health system stakeholders and clinical operations. Changing the framing from opt in to opt out had the effect of increasing participation in screening.

Discussion Themes

In some settings, choice overload can have a negative effect on participation.

When designing embedded pragmatic trials, researchers must be mindful not to increase burden on clinicians’ workflow.

While behavioral economics offers suggestions for how to increase colorectal cancer screening rates, its effectiveness in different contexts needs to be evaluated.

Read more about Dr. Mehta and colleagues’ study in Effect of Sequential or Active Choice for Colorectal Cancer Screening Outreach: A Randomized Clinical Trial (JAMA Network Open, 2019).

Tags
#pctGR, @Collaboratory1, @Shivan_Mehta

May 3, 2019: Effect of Financial Bonus Sizes, Loss Aversion, and Increased Social Pressure on Physician Pay-for-Performance: A Randomized Trial and Cohort Study (Amol Navathe, MD, PhD)

Posted on by Gina Uhlenbrauck

Speaker

Amol S. Navathe, MD, PhD
Assistant Professor of Medicine and Health Policy
University of Pennsylvania

Topic

Effect of Financial Bonus Sizes, Loss Aversion, and Increased Social Pressure on Physician Pay-for-Performance: A Randomized Trial and Cohort Study

Keywords

Behavioral economics; Performance incentives; Evidence-based quality-of-care measures; Primary care quality; Pay for performance; Value-based medicine

Key Points

  • Pay-for-performance (P4P) programs are increasingly being used by health insurers and healthcare systems to incentivize physicians to practice higher value medicine, yet the evidence for P4P to affect quality and value of care remains mixed.
  • Behavioral economic principles in this study included increased social pressure and loss aversion added to larger bonus sizes to evaluate whether the intervention would lead to higher achievement of evidence-based quality measures.

Discussion Themes

Study findings included that, while a larger bonus size was associated with significantly improved quality for chronic care patients relative to a propensity-matched comparison group, adding increased social pressure and the opportunity for loss aversion did not lead to further quality improvement.

Attrition during the trial contributed some variability to the analysis.

Read more about pay for performance in healthcare in JAMA Network Open (Navathe et al, 2019) and NEJM Catalyst (2018).

Tags

#behavioraleconomics, #pctGR, @Collaboratory1