Behaviour Economics in Rheumatology

Shyam Shah MD (Medicine), PDF Rheumatology (CMC Vellore)
Consultant Rheumatologist and Director, CU Shah medical college and hospital, Surendranagar, India

What is Behavioural Economics?

We are all experts when it comes to deciding the treatment strategy for our patients. However, despite an optimal strategy, outcomes may vary due to poor drug compliance or irregular follow-up (the human component). We often assume that individuals make rational decisions, but real-world human behaviour actually deviates and is greatly influenced by emotions and past experiences. Understanding human psychology and the economics of our behaviour can be a vital tool. Behavioural economics involves analysing the predictability of these irrational human behavioural patterns so we can anticipate and avoid them to improve patient outcomes. By integrating behavioural economics into our practice, we can design interventions that account for these deviations and promote better health outcomes. We may already be incorporating some of these interventions in our practice. However, a more structured approach can help us address both the psychological and economic factors that influence health behaviours.

What are the basic principles of Behaviour Economics?

Loss Aversion: Patients are more motivated to avoid loss than seek gain. Motivation to maintain drug compliance may be greater to avoid the worsening of their condition rather than to achieve potential improvements.

Framing Effect: Decisions are influenced by how information is presented. Telling a patient who needs to start Anti-TNF therapy that there is a 1% chance of TB reactivation might discourage them to do so but telling them that there is a 99% chance of not having TB might not.

Present Bias: Patients prioritise immediate comfort or gains over long-term health benefits. Smoking and obesity are greatest examples of this bias. GC bridging therapy (providing early relief) helps improve patient compliance and confidence in treating doctors. Monthly cash incentives to TB and HIV patients by the government provides short term gain that reinforces long term benefit.

Time Inconsistency: Patients’ preferences may change over time, leading to inconsistencies in adherence to treatment plans. Writing day of week for taking methotrexate, mentioning time for taking day and night medications in prescription, forms a commitment contract reinforcing compliance.

Status Quo Bias: Change requires effort. Patients tend to stick with their old treatment or lifestyle habits even if better options are available. ‘Opt out’ approach is more effective than ‘opt in’ approach

Social Norms: Patients are influenced by what they perceive others are doing. Group therapy sessions or patient support groups can encourage positive health behaviours.

Anchoring: Initial information provided to patients about their condition and treatment options can heavily influence their subsequent decisions. Providing accurate and comprehensive initial consultations is crucial.

Mental Accounting: Patients might treat health-related expenses differently from other expenses. Most people in India don’t plan for them. Financial counselling and clear explanations of the cost-benefit of treatments can help.

Endowment Effect: Patients may value their current treatment or routine more highly simply because they are emotionally attached to it. Demonstrating the superior benefits of new treatments can help them transition.

Overconfidence: Patients might overestimate their ability to manage their condition without professional help. Regular check-ins and education about the importance of professional guidance can mitigate this.

Availability Heuristic: Patients might overestimate the likelihood of a rare event (disease or side effect) if they have recently seen someone suffer from it or heard about it. Providing balanced information about risks and benefits can help manage these perceptions.

How can it improve my clinical practice?

Utilize Nudges and Defaults:
- Text Message Reminders: Sending automated text messages to remind patients about upcoming follow-up appointments can significantly improve adherence. For example, daily mobile reminders to take medications at a specific time, reduces the likelihood of missed doses. (Timing inconsistency)
- Default Options: Setting default options that favour healthy behaviours can be very effective. For instance, automatically enrolling patients in a physical therapy program unless they opt out can increase participation rates. (Status quo bias)
Incorporate Incentives and Rewards:
- Financial Incentives: Offering small financial rewards for patients who engage in healthy behaviours can motivate them to stick to their treatment plans. For example, insurance companies provide discounts on their healthcare premiums for people who maintain a healthy weight and lifestyle.
- Gamification: Turning health goals into a game can make the process more engaging. For instance, a mobile app that tracks physical activity and awards points for reaching daily exercise goals can encourage patients to stay active.
Leverage Social Norms and Peer Influence:
- Peer Comparisons: Showing patients how their behaviours compare to others can motivate them to improve. For example, a report card that shows a patient how their exercise frequency compares to the average in their community can encourage them to be more active.
- Group-Based Programs: Encouraging patients to join group exercise classes can leverage peer influence. For instance, a walking group for patients with arthritis can provide both social support and motivation to stay active.
Enhance Education and Health Literacy:
- Clear Information: Health information should be easy-to-understand and preferably in local languages.
- Messenger: People are influenced by who gives information. Treating physician is often the most trusted source of information. Spending some time counselling the patient can go a long way.
- Health Literacy Programs: Understanding the healthcare system can empower patients to take an active role in their care. For instance, workshops that explain how to read medication labels and understand prescription instructions can improve adherence.
Foster Social Support:
- Family and Community Engagement: Involving family members in the patient’s care can provide emotional and practical support. Educating them about the patient’s condition and how they can help with daily activities can improve the patient’s quality of life.
- Support Groups: Establishing support groups where patients can connect with others facing similar challenges can provide a sense of community and shared experience.

Most of these concepts are not communicated to us in our training programs or if they are we don’t pay attention to them. We usually tend to learn them passively through trial and error by dealing with our patients. However, utilising behavioural economics can shorten the time to realise this and greatly improve our patient health outcomes.