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October 1, 2007
  The Benefits of 'Not Checking the Box:' Default Options Should be Used to Improve Health Care
  Opinion Piece in New England Journal of Medicine Urges Greater Use of Automatic Decisions
   

(PHILADELPHIA) – Anyone who has ever tried to set up an internet account or wants to make a purchase on a company’s website, has experienced the ‘default option,’ an event or condition that will be set in place if no alternative is actively chosen.

In an opinion article in the September 28 issue of the New England Journal of Medicine, lead author Scott D. Halpern, M.D., a fellow in the division of Pulmonary, Allergy and Critical Care Medicine in the University of Pennsylvania Health System, and colleagues, argue that these concepts applied by marketers should also be used by the medical community to benefit patients. Additional authors are Peter A. Ubel, M.D., and David A. Asch, M.D., M.B.A.

When designed properly, the authors write, default options can achieve three goals:

  • Improve care for individual patients
  • Improve health care in hospitals and allied settings
  • Promote cost-containment and other social agendas.

The authors cite examples of potential default options that are easily implemented and would result in an overall benefit. “A policy to remove urinary catheters in hospitalized patients after 72 hours unless physicians or nurses document a reason for maintaining them, could reduce the hospital-borne infections.”

Organ donations are another example. The change from opt-in to opt-out policies has increased donation rates in many European countries, the authors note.

According to Halpern, “the current system allows defaults to be set haphazardly. Instead, physicians and policymakers have a great opportunity to set defaults in ways that help to improve the health of individual patients as well as our entire health-care system.”

Sometimes default options should not be used, however, and the authors note that these circumstances also need to be identified. The computerized patient order system, for example, which is used in most U.S. hospitals, should encourage physicians to actively select a specific dose for each medication ordered rather than defaulting to the lowest or the most popular dose. The absence of a default option forces physicians to consider the most appropriate dose for each patient and it should minimize the risks of overdosing or under dosing that these systems may generate.

Not only can health-care outcomes benefit from a thoughtful default strategy, the authors write, they can accrue cost-savings as well. “The policy whereby drug prescriptions default to generic medications unless physicians check a ‘brand necessary’ box promotes the social goal of decreasing health-care expenditures.”

Establish clear-cut options when it is a given that some action should be taken. “For example, patients who have trouble choosing between the recommended screenings for colon cancer—colonoscopy and sigmoidoscopy plus fecal occult-blood testing—may avoid either test. In such cases, a default option to either screening method should ensure that it is done.”

In conclusion, the authors state that “our current approach to default options in health care has itself been too passive, and opportunities exist throughout the health care system to use these options more strategically.

“Enacting policy changes by manipulating default options carries no more risk than ignoring such options that were previously set passively, and it offers far greater opportunities for benefit.”

###

David A. Asch, M.D., M.B.A., is Robert D. Eilers professor of Health Care Management and Economics at the University of Pennsylvania and executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania Health System.

Peter A. Ubel, M.D. is professor of Medicine and Psychology at the University of Michigan and director of the Center for Behavioral and Decision Sciences in Medicine.

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