Instant Gratification as a Method to Promote Physician Practice Guideline Adherence: A Systematic Review

Inadequate adherence to best practice guidelines may have a negative impact on the processes of critical care and patient outcomes. Instant gratification has been used to modify human behavior in industries such as gaming, lottery, and social media. We hypothesize that, if properly and purposefully utilized, IG can become a successful tool for encouraging best practice guideline adherence among critical care providers. Four major databases were searched with a medial librarian. Covidence application was used to identify studies pertaining to the instant gratification being used to improve provider adherence with best practice guidelines. A total of 712 studies were identified, and, through duplicates removal, title and abstract screening, and full-text screening, a total of 13 studies were included in the final review. The exclusion criteria used included the following: no provider gratification, wrong focus/intervention, wrong study design, patient-focused intervention, not generalizable, and no conclusion. There is a knowledge gap regarding instant gratification utilization to influence practice guideline adherence among providers. The intervention functions of the Behavior Change Wheel (BCW) were evident, especially ‘persuasion’ and ‘incentivization’, which are most pertinent to our field. The restorative process that promotes positive reinforcement can be a potential solution for alleviating inadequacies in guideline adherence. Examining interventions based on functions of the BCW has shown that an instant gratification process may have the potential in altering critical care providers’ behavior and improving guideline adherence. This review is the first step towards creating smart algorithms to instantly alert providers for their actions compliant with best practices. Developing, testing, and validating the algorithms will be the next several steps.


Introduction And Background
Utilizing physician adherence guidelines can decrease healthcare costs, improve health outcomes for patients, and standardize patient care [1]. However, lack of physician guideline adherence is one of the most prevalent problems in the healthcare system today [2]. Inadequate adherence results in nearly 269 million dollars wasted in treatments that are not beneficial to patients' health [3]. More importantly, non-compliance with treatment guidelines can also negatively affect a patient's health [2]. However, external barriers such as cost, and internal barriers, lack of knowledge, may make it challenging for healthcare providers to follow guidelines [1]. This may result in a deterioration in the quality of patient care [4].
Recent literature has explored the implementation of behavioral interventions that target patient-centered care [2]. Many of these interventions are based on techniques that have been effective in encouraging providers to follow recommended guidelines. However, it can be difficult to obtain physician buy-in for partaking, especially of those who are not inclined to [5]. Therefore, the development of an effective behavioral intervention requires a rigorous design process that addresses underlying issues that pose a barrier to guideline adherence [6].
One proposed method in developing an effective behavioral intervention is implementing instant gratification. As a phenomenon, it is usually associated with a negative connotation. Instant gratification can be utilized to positively reinforce behaviors that follow guidelines. Electronic health records (EHRs) could be a potential avenue to implement this strategy. The Clinical Decision Support Systems (CDSS) programs improve the quality of care for patients by suggesting additional assessments or test recommendations that the clinician can consider [7]. Recent studies have shown that this tool has been effective in evidence-based practice while also providing an additional resource for knowledge and support [7]. Utilization of CDSS is currently incentivized in the U.S as policy makers believe that the program can cut costs, provide timely reminders, and therefore improve quality of care [4].
In order to create a successful intervention that utilizes instant gratification and encourages adherence to guidelines, it is important to utilize the Behavior Change Wheel (BCW). BCW is intended to develop an intervention that analyzes the behavior in question [8]. The underlying hypothesis is that there is a relationship between one's capability (C), opportunity (O), and motivation (M) which explains why a behavior (B) is or is not observed (COM-B) [9]. COM-B could be used to investigate factors that elicit the desired behavior and therefore develop an effective intervention based on clinical context [10].
To date, there has been no behavioral intervention that utilizes instant gratification to improve physician guideline adherence. The purpose of this review is to show that, if properly and purposefully utilized, instant gratification can become a successful tool for encouraging targeted actions and behaviors.

Review Methods
We performed a literature review on instant gratification and behavioral interventions in medicine. We provided search terms to a librarian. The librarian searched in four databases (Medline, Embase, CINAHL, Web of Science). The Covidence application was used to identify studies pertaining to using instant gratification to improve physician adherence with practice guidelines. Publications were restricted between January 2009 and December 2018. The primary search term included one of the following: instant gratification, reward, immediate gratification, gratification, short-term gratification, pleasure, impulse, temptation, urge, motivation, or fulfillment. A secondary term, which accompanied the primary term, included one of the following: doctor, nurse, health care providers, healthcare, compliance, treatment compliance, practices, best practices, hospital, dopamine, prefrontal cortex, serotonin, ventral tegmental area, positive reinforcement. A total of 712 records were identified, and, through duplicate screening, title and abstract screening, and full-text screening, 13 studies were included in the final review ( Figure 1). The exclusion criteria used included the following: no provider gratification, wrong focus/intervention, wrong study design, patient-focused intervention, not generalizable, and no conclusion.

Results
The 13 included articles provided a wide variety of information pertaining to the study subject ( Table 1). The studies gave information on many of the intervention functions of the behavior change wheel (BCW), especially persuasion and incentivization, which are most relevant to the topic ( Figure 2). Intervention development and implementation were both detailed and analyzed, along with potential barriers to interventions.

FIGURE 2: Behavior Change Wheel
We identified 712 records from the literature search and narrowed the results to 13 articles. Of the 13 studies, three studies were reviews of the current literature of behavioral interventions in medicine [2,5,11]. 4 studies utilized the COM-B approach to rigorously evaluate the proposed behavioral intervention for each study [8][9][10]12]. Another 4 studies tested CDSS programs or modules and measured the frequency of guideline adherence or changes in provider behavior [1,4,6,7]. A total of 7 studies discuss intrinsic or extrinsic factors in healthcare that influence provider motivation [2,8,[10][11][12][13][14].

COM-B Approach
A total of 4 studies focused on the COM-B model to enhance their behavioral intervention. Utilizing semi-structured interviews allowed researchers to evaluate the current challenges of providers [8]. Participants are able to express uncertainties related to providing care [8]. Two studies cited that evaluating the clinical environment in terms of resources allowed researchers to create an intervention that addressed these barriers [8,12]. Action planning increased the likelihood that a provider could realistically implement the behavioral intervention in their own clinic [12]. COM-B allowed for researchers to identify the motivations and capabilities of their cohort before designing the intervention [9,10]. Identifying the motivations of individuals was important in enabling providers to elicit the desired behavior [9,10,12].

CDSS Programs
Four studies utilized CDSS programs or educational modules in the healthcare setting and measured changes in guideline compliance. Providers are likely to notice the notifications that CDSS provides, however they may not perceive it as influencing their behavior -although results may suggest that compliance increased [4]. One study suggested that CDSS increases compliance as it provides clarifications on guidelines for treatment [1]. AI programs increased the frequency of prescribing according to guidelines [6,7]. There was also an increase in selfefficacy in providers when utilizing e-modules [6]. One study noted that if there is a lack of resources available to the provider, online programs will not help compliance [1].

Factors Influencing Motivation
A total of 7 studies explored the influence of intrinsic and extrinsic motivation and changes in behavior. Providing financial incentives led to an increase in the quality of care [11,14].
Addressing external factors, such as lack of experience with procedures, or environmental structuring of healthcare professionals in teams, can influence international motivation and thus performance [2,8,10,12,13]. Organizations that implement audit and feedback programs observe a modest increase in desired behaviors [11].

Discussion
We evaluated the current behavioral interventions that have observed an increase in desired behaviors in healthcare providers. Although there are no studies that have investigated the correlation between instant gratification and guideline compliance, there is plenty of data to suggest that providers can elicit desired behaviors if the right tools are applied. Behavioral interventions utilizing the BCW showed promising results that elicited desirable changes in providers. The success of the BCW comes with its primary goal to evaluate the intervention thoroughly before execution, such as identifying participant motivations and barriers [9,10,12]. Providers that utilized CDSS programs were more likely to adhere to the guidelines and improved prescribing practices. Frequent reminders were a valuable tool for physicians as they provided suggestions for tests or treatment [1]. Individuals who are more motivated to take part in behavioral change techniques are more likely to exhibit the desired behavior [12]. This is fueled by the person's intrinsic motivation to change. External motivations, such as financial gain, can play a factor, however, it varies from person to person [14].

BCW Interventions
The BCW is a valuable tool that allows researchers to conceptualize targeted behavioral changes, apply the proposed change through an intervention, and then evaluate the results (BCW 1). Proposing an intervention using this method allows researchers to evaluate barriers that would otherwise prevent desirable outcomes [9,10,15]. By utilizing the COM-B method, investigators can develop a strong framework that can focus on a targeted behavior and the outcomes [3,8]. Jackson et al. (2014) encourage the COM-B method for behavioral outcomes related to adherence as it considers external factors that other methods do not consider [3,9]. Behavioral changes in medication adherence can be influenced by a number of external factors such as limited resources and access to healthcare can influence adherence [3,12]. Investigators emphasized the importance of evaluating factors that result in non-compliance through existing literature before executing the intervention [3].
Stewart et al. (2019) executed a behavioral intervention which aimed to increase the competency of providers in stroke rehabilitation clinics using the BCW [15]. Participants were found to retain competency in their role after training, were more enthusiastic in their roles, and were more confident in their skills [16]. Long term behavioral changes were observed, as providers were able to recall the learning that was done during the intervention, and felt more satisfied in their role [16]. Investigators stressed that active engagement on behalf of the participants was key to desirable outcomes [16].

Gambling Industry
The gambling industry is a useful comparison for evaluating the potential of instant gratification to elicit behavioral changes. Casinos and lottery games use systems in place to encourage the repetition of gambling behaviors [17]. This is because individuals are hypersensitive to rewards. Mental representations can make gambling more attractive to individuals, and those who have more positive implicit attitudes to gambling are likely to play [17]. By providing spaced intervals in which participants receive satisfaction, addictive behavior is elicited [18].
There is an attractiveness component to uncertain rewards. Intermittent wins and losses are integral to continued play as there is a stronger behavioral response to play when participants cannot predict when rewards come up [17]. Thus, intermittent reward schedules are more resistant to extinction [17]. Players will generally accept more frequent, smaller rewards over larger, longer to wait rewards as it provides a feeling of satisfaction and subjective feelings of pleasure [17,19]. Frequently occurring feelings of pleasure can encourage players to continue gambling, which can soon become a learned association [17]. Some individuals participate in gambling in hopes of monetary gain, however, it is the unpredictability of rewards that motivates one to continue playing [20].

Social Media
Social media usage is largely influenced by gratification, which leads to increases in media usage [21]. There is immediate satisfaction due to content generation and gaining recognition from other users [22], correlating with a positive relationship with social media use [23]. Pleasurable satisfaction can lead to addictive behavior and habit formation. Most users will utilize an online activity to seek gratification, which soon leads to a pattern of conditioned behaviors [24].
Most social media content is created on the basis of motivational factors such as entertainment or information-seeking [22]. If there are greater feelings of satisfaction, individuals are more likely to repeat the same activity [21]. Although specific gratifications are determined by different personality traits [22], once a user develops a habit through gratification, one can expect a self-feedback system in which the user will continue to utilize that medium [23].

Strengths
This study provides valuable information that suggests instant gratification can be utilized to increase guideline adherence in providers. The BCW has the potential to create an intervention that evaluates the needs of the targeted population while also addressing barriers to a specific behavioral response.
Second, the implementation of CDSS programs that suggest recommendations for patient care is highly underutilized, and this paper highlights the effectiveness of these systems. There is a plethora of data to suggest positive outcomes for providers that utilize CDSS programs to improve patient care, and if paired with instant gratification, there is the potential to make these outcomes sustainable in the long term.
Our study also highlights the importance of motivation in behavioral change. If participants are motivated to participate in behavioral interventions, they are more likely to meet the desired outcomes [16]. An important consideration during the pre-intervention phase is to investigate barriers that prevent the desired behavior from being observed. This likely hinders motivation.

Weaknesses
There are several weaknesses that exist in our study. First, there is limited data related to instant gratification in the healthcare setting. Although effective with developed gambling behaviors and with social media usage, these industries heavily rely on developing a habit in the form of an addiction. Many of these addictions develop implicitly. However, we are aiming to create a sustainable behavioral change where providers are intentionally motivated to improve patient care.
Another limitation is that none of our evaluated studies investigated instant gratification. Rather, they evaluated interventions that targeted a certain behavior, and reported outcomes. There is limited information related to instant gratification specifically. Many studies investigate gratification on a broader basis. The effectiveness of instant gratification in behavioral interventions is currently unknown.

Conclusions
In conclusion, there is the potential for instant gratification to encourage guideline compliance with healthcare providers. The BCW is a valuable tool that evaluates the barriers and motivations of individuals before developing an effective behavioral intervention. Much of the success of a behavioral intervention comes from the participant's motivation to elicit change. CDSS programs can influence provider behaviors by providing continual reminders to the user. If utilized with instant gratification, it could positively reinforce desired behaviors by providing encouragement to providers. This has the potential to increase guideline compliance if utilized correctly.
activities that could appear to have influenced the submitted work.