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November 21, 2017

'Nudges' just won a Nobel Prize. But they aren't a fix for medication noncompliance, study suggests.

Daily Briefing

Medication noncompliance "is a major problem," but interventions based on behavioral economics have not yet proven they can address the issue, Aaron Carroll, a professor of pediatrics at Indiana University School of Medicine, writes in the New York Times' "The Upshot."

What is pharmacy's role in population health?

According to a review published about 10 years ago in the New England Journal of Medicine, noncompliance was a factor in as many as two-thirds of medication-related hospital admissions in the United States, costing about $100 billion annually, Carroll notes.

Researchers have deployed many strategies to attempt to address noncompliance, Carroll says. "So far, there hasn't been much progress," he writes, citing a Cochrane review that found "'current methods of improving medication adherence for chronic health problems are mostly complex and not very effective.'"

Carroll states, "At first glance, behavioral economics—the basis of Richard Thaler's recent Nobel Prize in Economics—seems like a rich field of potential solutions," as it has demonstrated success in a variety of areas in "nudging" people to make desired choices.

However, while efforts rooted in the approach have led to success when it comes to organ donation and keeping patients from missing appointments, Carroll asserts that "those excited about the potential of behavioral economics [to address noncompliance] should keep in mind the results of a recent study."

For the study, researchers randomly assigned over 1,500 individuals who had recently had a heart attack to receive either usual care or be part of a test group. Test group participants received special electronic pill bottles that tracked their medication use.

On each day that participants took their drugs, they were entered into a lottery that gave them a 20% chance of winning $5 and a 1% chance at winning $50. Test group participants who enrolled in the lottery also could enroll in a program to notify a family member or friend if they didn't take their pill, and they could access special work resources and a staff engagement adviser.

But the effort "failed," Carroll states. The time to cardiovascular-related hospitalization was the same for both groups, the researchers found. The groups' medical costs were also the same.

Carroll suggests that financial incentives and behavioral economics might work better in public health than in direct health care. He cites the success of interventions related to weight loss—though success seemed to wane with time—and smoking cessation—which also came with caveats, Carroll notes.

"Behavioral economics may offer us some fascinating theories to test in controlled trials, but we have a long way to go before we can assume it’s a cure for what ails Americans," Carroll concludes (Carroll, "The Upshot," New York Times, 11/6).

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