ReviewLeveraging behavioral economics to promote treatment adherence: A primer for the practicing dermatologist
Introduction
Nonadherence to treatment is a pervasive and largely unacknowledged problem for those with chronic diseases, believed to account for over 100,000 avoidable deaths and $100 billion in unnecessary medical costs each year.1 Dermatologic conditions, which vary widely in pathology and treatment modalities, are not immune to this problem and similarly face suboptimal efficacy and safety outcomes as a result of nonadherence.2 This is perhaps best exemplified by psoriasis, a chronic inflammatory disease that affects an estimated 8 million Americans.3 This disease features a quality-of-life (QOL) burden comparable to that of diabetes mellitus or cancer, a financial burden amounting to an estimated $135 billion annually and low rates of treatment adherence.4, 5, 6, 7, 8 Despite the fact that multiple highly effective treatment modalities exist for psoriasis, an alarming 40% of patients do not adhere to their prescribed medications.9, 10, 11 This presents a serious concern for patients, as treatment adherence is necessary for the effective management of symptoms and sustained disease control.12 Moreover, improvements in adherence interventions may result in superior population-level QOL and economic outcomes than any improvement in specific medications.13, 14, 15 It is therefore essential that dermatologists explore novel approaches to increase treatment adherence in their patients.
In this article, we first discuss applications of select principles of behavioral economics to improve treatment adherence in dermatology using psoriasis as a disease model. Behavioral economics is an underutilized and potentially powerful strategy to better understand why patients may not take their medications as prescribed. Unlike traditional economists, who view people as rational actors consistently making decisions based on what will best further their self-interest, behavioral economists propose that human decision-making is irrational, yet predictably so.16
Underlying this concept is the Dual Process Theory, which describes 2 separate cognitive systems that simultaneously control choices: intuition (system 1) and reasoning (system 2). System 2 is characterized by thoughtful deliberation. System 1, the predominant force in guiding everyday decisions, is defined by quick, emotionally driven intuition that is repeated and observable.17 Behavioral economics in health care leverages these “predictably irrational” system 1 decisions to better encourage patients to make healthy choices, such as appropriately adhering to a therapy regimen.18
Central principles in behavioral economics that have been implemented and studied in health care settings include anchoring, decoy effect, framing, financial and social incentives, loss aversion, precommitment, present bias, regret aversion, and status quo bias (Table I).19, 20, 21, 22, 23, 24, 25, 26 Next, we briefly explore the ethical considerations related to the application of these principles.
Section snippets
Methods
We conducted a scoping review in PubMed on September 9, 2020 to identify articles that discuss behavioral economics and its application to treatment adherence in dermatologic patients, with a particular focus on psoriasis. When examples of the application of these principles in dermatology, or in psoriasis specifically, were not available, we searched for examples in other medical disciplines.
Conclusion
Patients with dermatologic diseases, like psoriasis, face high QOL and financial burdens comparable to those of other major chronic illnesses. While there exist several efficacious treatment modalities, suboptimal adherence necessitates the development of interventions that aim to overcome this obstacle. Behavioral economics offers promising approaches to the improvement of treatment adherence by leveraging our understanding of human decision-making. When used appropriately and in addition to
Conflicts of interest
Dr Merola is a consultant and/or investigator for Abbvie, Amgen, Bayer, Dermavant, Eli Lilly, Novartis, Janssen, UCB, Celgene, Sanofi-Regeneron, Biogen, Pfizer, BMS, and LEO Pharma. Drs Perez-Chada and Cohen, and Author Woodbury have no conflicts of interest to declare.
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Funding sources: None.
IRB Statement: Not applicable.
Reprints not available from the authors.