Nudging Teams toward Cost-Effective Health Care: Evidence from a Field Experiment in Surgery

The treatment for both surgeons and nurses consists of three components.

First, at the beginning of each OR shift, treated individuals who are scheduled to work the shift will receive a personally customized message to their mobile phone. The message comprises a general nudge as well as a set of input recommendations for each upcoming procedure. The nudge reads “Dear Dr./Nurse X, For the surgeries this morning we remind you to avoid unnecessarily opening disposable equipment”. Then, for each upcoming procedure, we provide the recommended input use for three randomly chosen candidate inputs. We ensure that only 1 of the three items is inexpensive in order to weigh our treatment toward higher value items.

Second, treated individuals have access to a website that includes a table of thresholds for all candidate inputs. Staff can use this website to check thresholds for inputs that are not included in the message and for unscheduled surgeries (due to emergency or last minute schedule changes).

Third, treated surgeons and nurses will receive a bi-weekly feedback message containing a figure that summarizes the actual usage of candidate inputs during the surgeries they conducted over the last 14 days, compared to the recommended amounts.

For details on how we chose candidate inputs, please see the pre-analysis plan.

2022-06-20

2022-12-31

input use (deviations from the recommendation), quality of care

Our main indicator of input use is deviations from the recommendation. Specifically, in addition to computing the median use of each input at the procedure level using baseline data, we also compute the standard deviation. Then, for each operation and input during the experiment, we compute how many standard deviations above (or below) the median input use was.

We use four indicators of quality of care: an indicator for surgery complication, re-surgery in the same department within 7 days, readmission to the same department of the hospital within 7 days, and death within 7 days. The indicator for surgery complication turns on if any of the following seven variables turns on: actual surgery time, transfer to cardiology department or ICU within 24 hours, imaging order after surgery, excess time in recovery ward, blood loss (hemoglobin levels after versus before surgery), kidney failure (creatinine levels after versus before surgery), and surgical site specific infection

See pre-analysis plan

See pre-analysis plan

All nurses and all surgeons in the Operating Rooms department will be invited to participate in the study via individual “introductory meetings” with the Study Coordinators in the months prior to the start of the study. During the meeting, the Study Coordinator will administer a short baseline survey to all participating nurses and doctors. After the baseline surveys are complete, we conduct the randomization. Half of surgeons and half of nurses are randomly assigned to the treatment group. This generates four types of teams, with different combinations of untreated and treated nurses and surgeons. The treatment period is planned to last for 9000 scheduled operations, which we estimate will take roughly 6 months. At the end of the treatment period, we conduct an endline survey with nurses and surgeons.

The randomization will be done in the office by a computer. Details are specified in the pre-analysis plan.

Doctor and nurse level

Yes

95 nurses and 156 surgeons.

9,000 scheduled operations plus any unscheduled operations that occurred during the time frame. (In case of additional waves of Covid-19, we might need to increase the the volume of surgeries to achieve balance across surgery types.)

Nurses: 47 treated, 48 untreated
Surgeons: 79 treated, 77 untreated