Category: Epidemiology, Health Policy, Socioeconomics & Outcomes

MP33-4 - Just a Nudge: Applying Behavioral Incentives to Engage Residents in Quality Improvement Education

Sun, Sep 23
2:00 PM - 4:00 PM

Introduction & Objective :

Health care researchers and policy-makers are increasingly applying behavioral incentives in medicine. Behavioral incentives can help overcome barriers to engagement in a variety of activities, including education. Quality improvement (QI) education is required for urology residents by the ACGME, yet engagement may suffer from a perceived lack of learner interest. Our objective was to compare resident participation in a urology-specific QI curriculum with two different behavioral incentives: team-based competition versus individual incentives.  


Methods :

We conducted a multicenter cluster randomized trial of ACGME-accredited urology residency programs stratified by size. Programs were randomized to either a team-based competition or an individual incentive environment. In both, residents participated in an identical QI program on Qstream®, a web-based, mobile-device-compatible platform. Biweekly for 12 weeks, residents received an email link to the platform that introduced 20 clinical-scenario-based questions. Immediate feedback and explanations were provided. In the team-based competition environment, weekly leader boards displayed team standings. In the individual incentive arm, residents were eligible for a weekly loss-framed incentive that required the winner be current on attempted questions. Our primary outcome was percentage of questions attempted. Secondary outcomes included participation, defined as attempt of at least 1 question, and mastery, correctly answering a question twice-in-a-row.


Results :

We enrolled 453 residents from 36 accredited urology residency programs. Significantly more residents participated in the team-based competition than the individual-incentive environment (71% vs. 58%, p=0.005). Residents in the team-based competition not only attempted a greater percentage of questions than those in the individual incentive environment (60% vs. 44%, p<0.001), but also mastered a greater percentage of questions (24% vs. 16%, p<0.001). Almost half of residents in the team-based competition, 45%, answered every question versus only one third of those in the individual-incentive arm, 33% (p=0.01).


Conclusions :

The inclusion of behavioral incentives in medical education enhanced resident engagement. Specifically, learner participation and knowledge mastery in a QI curriculum was increased with team-based competition. Additionally, we demonstrated the feasibility of national implementation of a specialty-specific QI curriculum. Further studies are needed to investigate the effects of behavioral interventions in other medical education contexts. 

Ashley W. Johnston

Duke University Medical Center, Division of Urology
Durham, North Carolina

Eugene B. Cone

Duke University Medical Center, Division of Urology
Durham, North Carolina

Jonathan Bergman

University of California Los Angeles, Department of Urology
Los Angeles, California

Tannaz Moin

University of California Los Angeles, Division of Endocrinology
Los Angeles, California

Arlene Fink

University of California Los Angeles, Department of Medicine
Los Angeles, California

B. Price Kerfoot

Harvard Medical School
Boston, Massachusetts

Charles D. Scales

Associate Professor
Duke University Medical Center, Division of Urology
Durham, North Carolina

Charles D. Scales, Jr., MD MSHS is Associate Professor of Surgery (Urology) and Population Health at Duke University School of Medicine and Vice Chief for Quality Improvement and Patient Safety in the Division of Urologic Surgery. He completed medical school and residency training in urology at Duke University Medical Center. After residency, Dr. Scales completed the Robert Wood Johnson Foundation Clinical Scholars Program at UCLA, where he received advanced training in health services research, health policy, and quality of care.

Dr. Scales has a strong interest in education, having previously served on the ACGME Review Committee for Urology and as a member of the ACGME Board of Directors. He currently leads a course in quality improvement and data analytics in the Masters of Management in Clinical Informatics program at the Duke University School of Medicine.

From the research perspective, Dr. Scales has a longstanding interest in the epidemiology of and patient care for urinary stone disease. Recent studies have redefined the burden of urinary stone disease in the United States, compared the effectiveness of dominant stone removal technologies, and identified new opportunities for improving patient-centered and policy-relevant outcomes, such as unplanned care after procedural interventions. His research and perspective on urinary stone disease has been highlighted in U.S. News & World Report, Reuters, NPR, and the Wall Street Journal, among other media outlets.

As a result of these investigations, he has an appointment at the Duke Clinical Research Institute where he leads a diverse health services and clinical research program. He has received research support from the National Institute of Aging, the American Geriatrics Society, and philanthropic funding, among other sources. Currently, Dr. Scales is the Principal Investigator for the Scientific Data and Research Center for the NIDDK Urinary Stone Disease Research Network (U01).