BEIR Workshop Program

NHLBI Workshop on the Integration of Behavioral Economics into Implementation Research (BEIR), to address Heart, Lung, Blood and Sleep (HLBS) Conditions

Bethesda, Maryland



More effective implementation strategies can be developed when an informed understanding of motivators of behavior change is incorporated within the implementation strategy.  Behavioral economics in implementation research (BEIR) is anchored in the premise that an implementation strategy can be explicitly designed and maintained to optimize the desired behaviors (i.e., actions) with ease, efficiency, and consistency, if one has identified the desired outcome(s) and the recommended behaviors/action(s) needed to support those desired outcomes (as specified in an evidence-based practice (EBP)).  Behavioral economics strategies include: performance assessment; choice architecture; hovering (i.e., observation); incentives, including behavioral nudges; maintaining consistency; making harms more immediate/salient; modelling behavior; remuneration; social proofs, etc..  Behavioral economic strategies incorporated within an implementation strategy to deploy an EBP are designed and tested to achieve the intended performance objectives recognizing importance of cultural context and patterns of behavior change.  Some intervention research projects and system-wide quality assurance programs for EBP for heart, lung, blood, and sleep disorders (HLBS) are now being sub-optimally designed. The use of BEIR may lead to less-disruptive, user-driven sustainable intervention strategies.

Executive Summary

The use of behavioral economic strategies to evoke appropriate decision making (behavior) in fulfillment of the objectives of EBPs for HLBS was well recognized. Our understanding of factors influencing behavior is continuing to evolve. Initially, we understood that in order for an optimal decision to be made, education and knowledge would need to be provided so that a correct decision would be made. More advanced behavioral theory recognized that people are rational and to change their behavior you give rewards or incentives.  More recent models of understanding of behavior, reflect the complexity of behavior.  It can be very important to recognize that people can be irrational in predictable ways.  It is critical to harness these biases and/or restructure the environment so that the best decisions are made, as intended by EBPs.  Participants emphasized the importance of extending on-going advancements: discernment of which BEIR approaches are easier or harder to implement for various HLBS conditions and why; need for information-driving behavior to be readily accessible and actionable; ability to describe behavioral economics as an approach in order educate the scientific community and to garner support and use of BEIR; critical need for clarification and extended discussion on the interface between behavioral economics strategies/models and implementation frameworks to support EBP implementation strategies; and, importance for on-going dialogue between behavioral economic and late-stage implementation research experts.  Participants emphasized the importance that the decision making process and the cultural context be accurately depicted. BEIR studies should be designed to reflect the realities of human behavior, humans employ heuristics, or mental shortcuts, to make decisions.  These shortcuts can be incorporated into the design of more effective implementation strategies. The integration of behavioral economics in implementation research is a promising approach that may lead to more-efficient, less-disruptive, and sustainable intervention strategies. The participants recognized that additional support and research is needed in order to understand interrelationship of behavioral economics and implementation research.  It is important to design BEIR studies with the goal that they be sustainable beyond grant funding — as such, the appropriateness of financial incentives should be carefully considered. The term "behavioral economics" was used to convey the rigor of the scientific method of the approach; some expressed concern that the term “economics” may be misleading for researchers who are not aware of BEIR constructs and methods. Participants were very enthusiastic about timeliness to convene the workshop as an effort to generate insights on successful strategies and evidence gaps, as highlighted below.  

Highlights of considerations to advance the use of BEIR to address HLBS disorders include:

  • The complexity of the decision making behavior needing to be made (e.g., prescribing decision versus changing complex social interaction) is an important factor.
  • For decisions which are made frequently, it may be more difficult to change decision making behavior, yet, the impact could be very significant.
  • Effectiveness of BEIR incentives have primarily been studied in the short-term.  It is critically important to look at sustainability and the long-term perspective. 
  • Patterns of appropriateness of which types of behavioral economic strategies should consider whose behavior is targeted to be changed.   For example, some patients may respond well to the regret lottery; while clinicians would more likely find other behavioral economic strategies to be effective.
  • Further exploration is warranted into which incentive designs, e.g., gamification, regret, timing, deposit contracts, variable reinforcement etc.,  may be particularly well-suited to induce a behavior change within a defined period of feedback.
  • Financial incentives often are not sustainable. Social nudges may be more sustainable over time.
  • Intrinsic motivators were identified as being difficult to capture in BEIR, across the levels of patients, care providers, groups, and system-wide procedures. Extrinsic motivators are more popular strategies in BIER, as they are identified as being easier to integrate in BEIR.  
  • Research is needed to challenge the assumption that external motivations should be transitioned into intrinsic motivations. Under which circumstances external motivations should be converted into intrinsic motivation approaches? Under which circumstances should external motivations be maintained over time?
  • Multi-level and multi-actor BEIR strategies are likely to be more effective strategies overall, than single-level or single-actor BEIR strategies. More empirical data are needed in order to understand the intersections of the multi-level and multi-actor systems. 
  • Microsimulation models may be helpful in simulating the long-term trajectory and cost-effectiveness of interventions.
  • Given the ongoing advancements in recognition of the importance of synergistic alignment of workflow and functionality of health information technology, it is important to generate more insights on the determination of choice architecture configurations, e.g., defaults, opt-in/out decisions, ordering, active choice and simplicity within a implementation strategy for EBP.  
  • To increase interest and recognition for the field, wide dissemination of the basic approaches needs to be increased across members of the multidisciplinary implementation research team. 
  • Providing training in behavioral economics across NIH institutes, is one way to promote the importance of skill development and application of behavioral economics. 

Workshop Chair

  • Rebecca Roper, M.S., M.P.H., Project Officer, Center’s for Translation and Implementation Science (CTRIS), NHLBI

Work Group Participants/Moderators in Order Listed in Workshop Agenda 

  • George Mensah, M.D., FACC, Director, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Catherine Stoney, Ph.D., Deputy Director, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Rinad Beidas, Ph.D., Associate Professor, Perelman School of Medicine, University of Pennsylvania
  • Susan Shero, M.S., B.S.N., Program Officer, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Joyonna Gamble-George, Ph.D., AAAS Fellow, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Jazmin Bustillo, M.S., Program Specialist, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Mark Parker, Senior Program Support, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Mary Masterson, Ph.D., AAAS Fellow, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Cheryl Anne Boyce, Ph.D., Branch Chief, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Jennifer Curry, M.P.H., Program Analyst, Center’s for Translation and Implementation Science (CTRIS), NHLBI
  • Kathleen Fenton, M.D., Deputy Chief, Division of Cardiovascular Science (DCVS), NHLBI
  • Lora Reineck, M.D., M.S., Program Director, Division of Lung Diseases (DLD), NHLBI
  • Joseph Ladapo, M.D.,Ph.D., Associate Professor, University of California Los Angeles
  • Pamela Peterson, M.D., M.S., M.S.P.H., Professor of Medicine, Department of Medicine, Denver Health
  • Davene Wright, Ph.D., HDFS, Faculty, Harvard Medical School
  • Shivan Mehta, M.D., M.S., M.S.H.P., Associate Chief Innovation Officer, Penn Leonard Davis Institute of Health Economics
  • Andy Ryan, Ph.D., UnitedHealth Care Professor of Health Care Management, University of Michigan School of Public Health
  • Daniel Max Crowley, Ph.D., Associate Professor of Human Development, Family Studies & Public Policy, Pennsylvania State University 
  • Melissa Green-Parker, Ph.D., Health Scientist Administrator, Office of Disease Prevention (ODP), NIH  
  • Josh Fessel, M.D., Ph.D., Project Officer, Division of Lung Diseases (DLD), NHLBI 
  • David Asch, M.D., M.B.A., Executive Director, Wharton University of Pennsylvania 
  • Stephen Persell, M.D., M.B.A., Professor of Medicine and Director, Center or Primary Care Innovation, Northwestern Medicine 
  • Sara Bleich, Ph.D., Professor, Public Health Policy, Harvard T.H. Chan  
  • Sharon Smith, Ph.D., Program Officer, Division of Blood Diseases and Resources (DBDR), NHLBI
  • Michelle Freemer, M.D., M.P.H., Project Officer, Division of Lung Diseases (DLD), NHLBI
  • Phaedra Corso, Ph.D., M.P.A., Professor and Vice President, University of Georgia’s (UGA) College of Public Health 
  • Douglas Hough, Ph.D., Senior Associate, John Hopkins School of Public Health 
  • Joanne Yoong, Ph.D., Senior Economist, USC Dornsife Center for Economic and Social Research 


12:00 p.m.
Welcome and Workshop Objectives: Rebecca A. Roper, M.S., M.P.H.

12:05 p.m.
Introductions of NHLBI Participants and Workshop Invitees

12:20 p.m.
Opening Remarks: George Mensah, M.D.

12:25 p.m.
Intersection of Behavioral Economics and Implementation Science:
Presenter: Rinad Beidas, Ph.D., Moderator: Rebecca A. Roper, M.S., M.P.H.

Open Discussion/Clarifying Questions
Discussants: All Subject Matter Experts, Reporter: Susan T. Shero, M.S., B.S.N. 

1:00 p.m.
Use-Cases from NIH Grantees: How can behavioral economics be integrated into an implementation strategy for evidence-based practice to help achieve the envisioned impact on health and healthcare?
Moderator:  Cheryl Anne Boyce, Ph.D., Reporters: Kathleen Fenton, M.D. and Lora Reineck, M.D., M.S.

Use-Case Presentations: (5 minutes each)

Joseph Ladapo, M.D., Ph.D.  
Behavioral Economics and Implementation Research to Reduce Cardiovascular Risk in HIV-Infected Adults

Pamela Peterson, M.D., M.S., M.S.P.H. 
Enhancing Cardiac and Pulmonary Rehabilitation Adherence Through Home-based Rehabilitation and Behavioral Nudges: E.R.A. Nudge 

Davene Wright, Ph.D.  
Behavior Modification or Commodification? Using Behavioral Economics to Improve Child and Adolescent Obesity Management  

Shivan Mehta, M.D., M.S., M.S.H.P. 
EMPOWER: Pragmatic Randomized Trial of Automated Hovering in Patients With Congestive Heart Failure  

Andy Ryan, Ph.D. 
Using Behavioral Economics to Improve Cardiovascular Outcomes in the Merit-Based Incentive Payment System 

Max Crowley, Ph.D. 
Example of BEIR Use-Case Under Development 
Execute Polling Questions 1 and 2 

Discussion Questions
Moderator: Cheryl Anne Boyce, Ph.D., Discussants: All Subject Matter Experts Reporters: Kathleen Fenton, M.D.; Melissa Green Parker, Ph.D.

  1. What are the different strategies to help people navigate environments when translating insights into behavior changes for patients, care providers, groups, and system-wide procedures?
  2. How do the various incentive designs, e.g., intrinsic and external motivational elements, fit into the research designs and objectives?
  3. How can behavioral science and health economics be used in implementation research to promote equity?

2:10 p.m.

2:25 p.m.
Behavioral Economics: Special Considerations in Implementation Research
Moderator: Josh Fessel, M.D., Ph.D.

David Asch, M.D., M.B.A. 
Participant Consent and Validity in Studies about Health Behavior Interventions. 

Steven Persell, M.D., M.P.H.  
Health Systems Research using I.T. for Delivery and Moving from Pilot to System 

Sara Bleich, Ph.D. 
Improving the Reach and Impact of Scientific Communication 

2:45 p.m.
Discussion Questions
Moderator: Josh Fessel, M.D., Ph.D., Discussants: All, Open Session, Reporters: Sharon Smith, Ph.D. and Michelle Freemer, M.D., M.P.H.

  1. Which BEIR approaches are easier and which are harder to implement for HLBS diseases? Why?
  2. What are additional research design considerations needed in planning for a BEIR? To what extent are clinical trial research designs as defined by NIH, necessary for BEIR?
  3. What are the behavioral economics models, and do they differ from current implementation frameworks?
  4. How do we encourage more behavioral economics and implementation research in HLBS areas?
  5. Beyond traditional peer-reviewed journals, where and how should we disseminate results?

4:00 p.m.
Moderators: Rebecca A. Roper, M.S., M.P.H. and Joyonna Gamble-George, Ph.D.

Next Steps: Cheryl Anne Boyce, Ph.D.

5:00 p.m.
Meeting Adjourns