PONE-D-23-33529Assessing a behavioral nudge on healthcare leaders’ intentions to implement evidence-based practicesPLOS ONE

Dear Dr. Crawford,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The reviewers have endeavored to provide numerous constructive suggestions to improve the article. Please take them into account. In particular, following the reviewers’ comments, please provide more details about how the intervention was delivered, as well as a more and better developped discussion. Please submit your revised manuscript by Feb 29 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Alberto Molina Pérez, Ph.D.

Academic Editor

PLOS ONE

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“This work was supported in part by the Agency for Healthcare Research and Quality's (AHRQ's) Comparative Health System Performance Initiative under Grant # 1U19HS024075, which studies how healthcare delivery systems promote evidence-based practices and patient-centered outcomes research in delivering care (MC, JO, EM, TF, AB) (ahrq.gov). It was also supported by the Levy Cluster in Healthcare Delivery at Dartmouth College (AB) (https://sites.dartmouth.edu/levyincubator/).”

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“Contributors: The authors thank Kristy Bronner and Emily Luy Tan for their research support.

Funders: This work was supported in part by the Agency for Healthcare Research and Quality's (AHRQ's) Comparative Health System Performance Initiative under Grant # 1U19HS024075, which studies how healthcare delivery systems promote evidence-based practices and patient-centered outcomes research in delivering care. It was also supported by the Levy Cluster in Healthcare Delivery at Dartmouth College. The statements, findings, conclusions, views, and opinions contained and expressed in this article are based in part on data obtained under license from IQVIA information services (OneKey subscription information services 2010-2017, IQVIA incorporated all rights reserved). The statements, findings, conclusions, views, and opinions contained and expressed herein are not necessarily those of IQVIA Inc. or any of its affiliated or subsidiary entities. The views presented herein do not represent those of the Federal Government.”

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This study examined whether a letter with social norms messaging and peer comparison data

impacted healthcare leaders’ decision to access a website with resources to support

evidence-based practice adoption. The team conducted a pragmatic, randomized controlled trial of 2,387 healthcare leaders from health systems, hospitals, and physician practices in the United States to receive one of two cover letter versions, each linking to a resource website and accompanying a report with survey results. The “nudge” letter included messaging that highlighted how an organization’s results compared to peers using text, color, and icons. The letters were sent in Dec 2019 and emails and followup emails were sent Dec 2019 and Jan 2020 to those with email addresses. The team interviewed 14 participants to understand how the letter and report impacted behaviors. 1.8% of the leaders sent the nudge letter accessed online resources, compared to 1.4% sent the control letter (p=0.424).

Overall, this study makes an excellent contribution to several areas of the literature in terms of applied behavioral science and nudge interventions in health care, health care quality improvement, and implementation science. The nudge literature has been criticized for publication bias. It’s critical that rigorous randomized trials with null findings like this are published to better understand what works and what doesn’t. The nudge interventions were well conceived and it’s likely that many would have thought they could be effective at increasing engagement with quality improvement interventions. The results will be informative to quality improvement leaders as they plan future interventions to increase adoption of evidence-based practices.

I have some recommendations for improving the paper and it’s impact:

1. More clarity needed in description of how the intervention was delivered.

a. I had to read through the methods and the supplemented several times to understand how the intervention was delivered. It should be stated more clearly that the letters were sent by postal mail to all individuals who were randomized and that an email was sent to ~60% of the randomized individuals who had an email address. S1 Figure 1 makes this much more clear than Figure 1. S1 Figure 1 should be included in the main manuscript instead of the current Figure 1.

b. Given that over 86% of those who were emailed the letter didn’t open the email, it’s critical to know what the subject line of the email was. This should be stated in the manuscript and included in the supplement.

c. It should also be more clearly stated that the email required a login step to get into the report

2. Calling out important exploratory outcomes in the Results. This is mentioned in the discussion, but not called out in the Results.

a. The fact that unique website resources downloads was no different, and likely even more common in the control group is something that should be called out because that’s the final behavior the researchers are trying to improve. This is less that 2% overall of intended recipients, indicating that the efforts were unsuccessful for 98% of the targeted recipients.

3. Discussion and key lessons need to be reframed around the major findings of the trial.

a. Last line of the discussion 266-267 – “The qualitative results, however, suggest

that providing administrative leaders with data comparing their organization’s performance to that of peers can spur follow-up action aimed at promoting evidence-based practice adoption” needs to be reframed. These qualitative results were only collected among 2% of the intended recipients who engaged with the intervention. Would reframe the qualitative findings to be among the small proportion of the intended recipients who engaged with the intervention. Furthermore, the qualitative methods are limited and don’t include a conceptual model and with very little description of how the responses were coded and analyzed. I would worry that the quotes were cherry picked to add some positive findings around the intervention. I’m not sure that very much can be concluded from the qualitative analysis since engagement was so low and engagement is likely reflective of highly motivated individuals. This is even stated as a limitation at the end that “ the qualitative interviews were conducted with a small sample, so it is hard to draw broad-based conclusions from them.”

b. The stated three lessons from the results do not align closely with the key findings of the trial, particularly the first two: “1) peer comparison data can be powerful…and 2) Outcome variables should align.” The key finding of the study is that a letter distributed through postal mail and email was that 86% of health care leaders didn’t open the email, and only 1.4% of the leaders visited the website with implementation resources. The other key finding was that even among the few who engaged, there wasn’t a significant difference in engagement according to whether the letter was reframed with insights from behavioral science. This suggests that biggest opportunity is around how to engage and capture the attention of health care leaders. This is a much bigger opportunity that trying to optimize messaging once engaged.

c. Much more emphasis of the discussion should be focused on what is known re engagement/open rates of letters/emails for engaging health care leaders and clinicians. The findings should be placed in this context and opportunities to optimize in the future including the messenger, subject line, and steps to decrease friction to reaching web resources (getting rid of login steps).

d. I suspect that one factor associated with low engagement in Dec 2019 and Jan 2020 among health care leaders was that there was a deluge of email communications and meetings occurring around that time with regards to planning for the Covid-19 preparedness and also December and January are difficult times to engage health care leaders since this is the beginning of budget planning season and there many high priority meetings stacked just before and after the holidays. It may be worth repeating at other times of year outside of the emergence of a new pandemic.

e. It seems like a major missed opportunity here was a lack used-centered design and feedback from health care leaders and pilot testing of alternative nudge strategies before full deployment. Little details of design can have outsized impacts. This should be highlighted as opportunity for future optimization.

Reviewer #2: The study explores the efficacy of a behavioral nudge in influencing healthcare leaders.

A total of 2387 healthcare leaders in the United States were randomized to receive one of two types of cover letters. Both letters provided a link to a resource website and a report with survey results, but the "nudge" letter included additional elements like text color and icons to highlight how an organization’s results compared to the peers.

There were no statistically significant effects of the intervention on website access, and regardless of cover letter format, website access was low, with less than 2% of all organizational leaders targeted, clicking through to website resources.

According to the authors, the qualitative results suggest, however, that providing administrative leaders with data comparing their organization’s performance to that of peers can spur follow-up action aimed at promoting evidence-based practice adoption.

Study Design and Methodology:

The pragmatic parallel-group randomized controlled trial approach is appropriate for the study's objectives. However, the manuscript would benefit from elaborating on the selection criteria for these leaders.

The distinction between the "nudge" letter and the control letter should be more pronounced in the manuscript. A clearer explanation of the specific elements used in the nudge letter (e.g., text color, icons) and -especially - how they are expected to influence behavior, would be beneficial.

The manuscript should include a more comprehensive discussion on the implications of the relatively low response rate (1.8% for the nudge letter and 1.4% for the control letter).

Literature Review and Theoretical Framework:

The introduction provides a good foundation for the study, highlighting the challenges in integrating evidence-based practice in healthcare and the role of behavioral nudges. However, it could be strengthened by incorporating more recent literature to establish the current state of research in this field. This would position the study more firmly within the existing body of knowledge.

The manuscript should explore in greater depth the theoretical underpinnings of nudging in the context of healthcare leadership. Discussing theories of behavioral economics in relation to healthcare leadership decision-making could provide a richer theoretical framework.

Results and Discussion:

The discussion section is unsatisfactory at the moment. It needs to delve deeper into the implications of the results. Specifically, a more critical analysis of why the nudges did not significantly increase website access is needed.

The qualitative insights from the interviews are valuable but are not sufficiently integrated into the overall discussion. A more thorough analysis of these insights in relation to the quantitative findings would offer a more nuanced understanding of the study's implications.

Technical Aspects and Presentation:

The manuscript generally follows a clear structure, but there are areas where the flow can be improved for better readability. For example, transitions between sections, particularly between the methodology and results sections, could be smoother.

In summary, the manuscript presents an interesting study with potential implications for healthcare leadership and practice. However, to fully realize its contribution to the field, the above-mentioned revisions are necessary. The focus should be on strengthening the theoretical framework and deepening the analysis of the results (both quantitative and qualitative).

I would also suggest to extend the Conclusions section of the article.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-23-33529R1Assessing a behavioral nudge on healthcare leaders’ intentions to implement evidence-based practicesPLOS ONE

Dear Dr. Crawford,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR: Please address the reviewers' feedbacks and suggestions to further improve your work.

==============================

Please submit your revised manuscript by Oct 07 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Laura Brunelli, MD, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors did a very nice job responding to the reviewer critiques and suggestions. This will be a nice contribution to the literature.

Reviewer #3: The authors report on a randomized control trial undertaken to test the effectiveness of focused communication strategies, informed by behavioural nudge theory, in influencing healthcare leaders to adopt evidence-based care delivery practices. The novel aspect of this study is the focus on healthcare leaders as opposed to clinicians given that these leaders often have the decision-making authority to promote and oversee the implementation of improvements. The methods were described in sufficient detail and were appropriate for the study aims. Ethics approval for the study was noted. The statistical analysis was appropriate given the limited data to be analyzed. The qualitative analysis of the transcribed interviews was explained briefly but with sufficient detail given the purpose of the study. The discussion flowed logically and considered important ways to understand the findings. The limitations were realistic and demonstrated important insights into the challenges experienced in conducting the study. Despite the very low response rate for the quantitative measure to assess the intervention outcome (visiting the website resources) and the non-significant statistical results, the report offers many insights into the issue of how organizations adopt evidence-based change and likewise how to study the impact of strategies to promote adoption through the use of nudge theory. Overall, the study report is well written and was a pleasure to read.

While there are no critical gaps in the report, a few suggestions are offered for consideration only. They reflect my limited knowledge of nudge theory and the desire to understand some aspects of the study in more detail. Some minor edits are also mentioned.

Introduction – It might be useful to add more detail about nudge theory to briefly explain the mechanism by which people (i.e., leaders) are influenced. As I read the paper, I also wondered how nudge-based strategies fit (or not) into implementation science concepts.

Table 2 – I was confused by the use of the notations ‘a’ and the asterisk as the explanation at the bottom of the table does not differentiate ‘a’ from ‘*’. As it is currently stated, only an asterisk is needed.

Table 3 – The qualitative themes and exemplars are described clearly. I was left wondering if there were any comments about the nature or quality of the nudge messaging specifically. Most the themes were about actions but not the qualities of the actual intervention (social norm messaging and comparison charts).

Discussion – It would be useful to link back the original aim and mention nudge theory or strategies. The word ‘nudge’ only appears twice on page 15 but nowhere else in the discussion section onward. Since nudge theory played an important role in the design of the intervention (and it is in the report title), it would be useful to explicitly state what has been learned about nudge-based strategies and this field of study.

Figure 1 – The final box under each arm of the randomized groups (bottom of diagram) seems redundant i.e. ‘allocated to control letter’ and ‘included in the analysis’ are the same numbers. The diagram could logically end with the box for ‘received allocated intervention’.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Assessing a behavioral nudge on healthcare leaders’ intentions to implement evidence-based practices

PONE-D-23-33529R2

Dear Dr. Crawford,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Laura Brunelli, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: