Part I|| Part II|| Part III|| Part IV|| Part V || Part VIPart VII@Makeuya
Nudge: Examines defaults in a healthcare context, by randomly assigning 132 seriously ill patients to complete one of three types of advance directive. Two types had end-of-life care options already checked – the defaults – but Group 1 favored comfort-oriented care and Group 2 favored life-extending care. Group 3 was a standard advance directive with no options checked. The authors found that while most patients wanted comfort-oriented care, the defaults influenced those choices.
Group 1 (comfort-oriented) - 77% of patients in the comfort-oriented group kept that choice.
Group 2 (life-extending) - 43% of patients in the life-extending group rejected the default and selected comfort-oriented care instead.
Group 3 (no default) – 61% of patients selected comfort-oriented care.
The authors findings suggest that patients may not hold deep-seated preferences regarding end-of-life care.
Tags : healthcare / defaults
Source: Loewenstein et al (2013), ‘Default Options In Advance Directives Influence How Patients Set Goals For End-Of-Life Care’, Health Affairs.
Nudge: These are two papers looking at the efficacy of checklists in surgery for reducing patient complications. The Haynes paper examined checklists in eight hospitals in eight cities. They found the rate of death for patients undergoing surgery fell from 1.6% to 0.8% following the introduction of checklists. Inpatient complications also fell from 11% to 7%.
The Arriaga paper had 17 operating-room teams participate in 106 simulated surgical-crisis scenarios. Each team was randomly assigned to work with a checklist or without and instructed to implement the critical processes of care.The results were striking; checklist availability reduced missed steps on the processes of care from 23% to 6% [See graph, CI bars indicate 95% confidence]. Every team performed better when checklists were available. Lastly, and I commend the authors for the design of this question that elicited this answer, “97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used.”
Both of these papers have Atul Gawande as co-author, who wrote ‘Checklist Manifesto’.
Tags: checklists / salience / healthcare
Source: Haynes et al (2009), ‘A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population’, The New England Journal of Medicine.
Arriaga et al. (2013), ‘Simulation-Based Trial of Surgical-Crisis Checklists’, The New England Journal of Medicine.
Nudge: A RCT focusing on encouraging to improve warfarin adherence via lotteries. The RCT placed 100 patients into a treatment group of daily lottery-based incentives or a control group with no such incentives. In contrast to previous research (see Nudge #9) the results did not show significant differences for adherence between the control and treatment groups.
Tags: healthcare / incentives / lotteries
Source: Kimmel et al (2012),'Randomized trial of lottery-based incentives to improve warfarin adherence', American Heart Journal.
Nudge: This paper also looks at medicinal adherence but through the medium of active choice; that is where there is no default but patients are required to make healthcare choices. The authors go slightly further than this and test what they call ‘enhanced active choice’ where one alternative is favored by highlighting the losses entailed by the non-preferred alternative – a true nudge if there ever was one. They tested the method by asking employees if they wanted to be reminded about receiving a future flu-shot.Results showed that enhanced active choice was by far the most effective method at inducing compliance.
Tags : active choice / healthcare / automatic enrollment / persuasion
Source: Keller et al. (2011), 'Enhanced active choice: A new method to motivate behavior change', Journal of Consumer Psychology.
Nudge: The authors, reasoning that people fail to identify with their future selves sufficiently to save enough for retirement, showed participants realistic age-progressed renderings of themselves to make the need to save more salient. Participants could decide how much they wanted to save on a slider: if they indicated a low amount, they saw a age-progressed rendering of themselves frowning. If they indicated a high amount, they saw the same figure smiling. Results showed participants had an increased tendency to accept later monetary rewards over immediate ones.
Tags : time discounting / present bias / retirement saving / future self-continuity
Source: Hershfield et al. (2011), ‘Increasing Savings Behavior Through Age-Progressed Renderings of the Future Self’, Journal of Marketing Research.
Nudge: This paper looks at the effects of reducing plate size and providing social cues on food consumption on food waste in hotel restaurants. An example of the latter is a salient sign saying “Welcome back! Again! And again! Visit our buffet many times. That’s better than taking a lot once”. Both treatments proved to be effective at changing eating behavior, reducing food waste by 20%.
Tags: food waste / eating
Source: Kalbekken (2011), ‘`Nudging’ hotel guests to reduce food waste as a win–win environmental measure', Economics Letters.
The authors predicted that the participants would interpret saving 150 lives as diffusely good, whereas saving 98% of 150 people is something clearly very good. The results confirmed this hypothesis, as is evident in the graph. Interestingly even the chance to save 85% of 150 (that is 127.5 people) attracted more support than the chance to save 150 outright.
This has interesting implications for, for example, how charities might best appeal to people to elicit donations.
Tags: framing / affect heuristic / risk analysis
Source: Slovic et al (2002), ‘Risk as Analysis and Risk as Feelings: Some Thoughts about Affect, Reason, Risk, and Rationality’, Risk Analysis.
Nudge: This paper delineates the diminishing sensitivity in valuing lifesaving interventions when there is an increasing number of lives at risk. The authors call this tendency “psychophysical numbing”, represented in later research by the “collapse of compassion” model.
For illustrative purposes, the top image to the right represents a normative model of how we should value human lives, the bottom image represents the collapse model that this research investigates.This paper has 3 studies illustrating psychophysical numbing in different contexts. In one study subjects had to decide which medical institution to award $10 million to – A, B or C. Subjects had to indicate how many lives would have to be saved by the treatment to merit receiving the award.
A – Would save 15,000 lives.
B – Would save 160,000.
C – Would save 290,000.
65% of participants gave estimates that increased as the size of the population at risk increased (indicating something like the collapse model is at work). Only 28% gave required that the same number be saved, regardless of population size (indicating a normative model).
If you are interested in this area I encourage you to read the other studies in the paper.
Tags: affect heuristic / diminishing sensitivity /
Source: Slovic et al. (1997),‘Insensitivity to the Value of Human Life: A Study of Psychophysical Numbing’, Journal of Risk and Uncertainty.
Nudge: This paper examined the average donations received when participants were presented with an identifiable victim (a girl named Rokia) versus a dry statistical overview of the problem. The greatest amount of donations were elicited by Rokia alone, even more so than a combination of statistics and a picture of Rokia.
Tags: affect heuristic / framing / charitable donations
Source: Small et al. (2007),‘Sympathy and callousness: The impact of deliberative thought on donations to identifiableand statistical victims’, Organizational Behavior and Human Decision Processes.
Nudge: Similar to the previous nudges, this paper found that people’s willingness to donate to identified victims not only decreased by increasing the number of victims from 1 to 8, but that their sympathy towards the victims also decreased. This would seem to further support the psychic numbing theory. Study 2 used a 2x2 design of (single victim vs group) x (identified provided victim vs unidentified) and examined peoples’ Willingness to Contribute, feelings of distress and empathy towards the victims. Results showed people donated more to the individual victim rather than the group of 8 when both were identified (i.e. name, age and picture provided) but donated more to the group when both were unidentified. This is with the proviso that standard deviations were quite large for monetary donations. Of the 4 conditions, participants felt the most distress and empathy for the identified single victim.
Tags: affect heuristic / framing / charitable donations
Source: Kogut & Ritov (2005). 'The "Identified Victim" Effect: An Identified Group,or just a Single Individual?', Journal of Behavioural Decision Making.