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Recent shortages of life-saving drugs highlight that drugs, like other forms of healthcare capital, are a limited resource. This issue is especially relevant to critically ill patients because many of the current drug shortages are injectable forms of drugs commonly used in ICUs (1). Drug shortages can negatively impact patients' welfare through treatment delays, medication errors, and use of inferior alternative drugs (2). President Obama recently issued an executive order that broadens federal requirements for manufacturers to report potential drug shortages. Although this is an important step, it may be insufficient to avert shortages unless it is paired with changes in how physicians prescribe scarce drugs.We draw on principles of behavioral economics to propose four strategies to influence how providers prescribe scarce drugs.
Providers' drug-prescribing behaviors are a major contributor to demand for certain drugs and are often shaped by factors other than strong empirical evidence, such as habitual patterns, lack of knowledge, and pharmaceutical company drug detailing (3, 4). For example, in our experience, clinicians in ICUs often habitually prescribe "a favorite" antibiotic for patients with healthcareassociated pneumonia, even though reasonable alternatives exist. Habitual prescribing practices become problematic when the drug prescribed is in short supply. For example, N-acetylcysteine is the treatment of choice to prevent acute liver failure from acetaminophen toxicity; it is also commonly prescribed for the prevention of contrast-induced nephropathy, despite evidence that N-acetylcysteine is not superior to intravenous fluids (5). Recent national shortages of N-acetylcysteine (inhalation solution used for oral use) have been exacerbated by its habitual use for contrastinduced nephropathy. This poses a serious risk of unnecessary harm to patients with acute liver failure, for whom there is no comparably effective therapy. Other problematic examples of habitual prescribing include use of certain intravenous antibiotics and electrolyte replacements (e.g., trimethoprim-sulfamethoxazole and potassium phosphate) rather than plentiful, equivalent oral agents (6, 7). The risk of unnecessary harm to patients from shortages is sufficient ethical justification to attempt to influence physicians' prescribing behavior.
A FRAMEWORK FOR MODIFYING PROVIDERS' PRESCRIBING PATTERNS DURING DRUG SHORTAGES
Behavioral economists integrate the disciplines of psychology and economics to understand factors that shape individuals' decisions (8). Several decades of research have established that, rather than acting in purely rational ways, people sometimes make counterproductive decisions due to biases...