Behavioural insights in the underuse of cardiac resynchronisation therapy in heart failure: a pilot survey on incentive perceptions among referring cardiologists

Background/Introduction Despite strong evidence and clear guideline recommendations, Cardiac Resynchronisation Therapy (CRT) remains underused, with only one-third of eligible patients receiving the therapy. Conventional efforts to improve uptake, including guideline dissemination, reimbursement structures and informational strategies, have shown limited impact. Behavioural economics offers a complementary framework by addressing cognitive mechanisms such as status quo bias, availability bias, knowledge resistance, and loss aversion, which shape referral inertia. Purpose To evaluate cardiologists' perceptions of traditional incentives and behavioural-economic strategies aimed at improving CRT referral behaviour. Methods A brief online survey was disseminated through cardiology department mailing lists, London School of Economics networks, and personal contacts of the study team. Clinicians were encouraged to share the link further within their local networks to reflect real-world referral pathways across both outpatient and hospital settings. No reminders were sent. Fifty-one physicians (electrophysiologists, heart failure specialists, and general cardiologists) rated five strategies on a Likert scale (1–5). These included traditional incentives (financial levers and informational/administrative strategies) and behavioural interventions such as choice-architecture nudges (electronic health records prompts, EHR) and social incentives (peer comparison). Medians and interquartile ranges were calculated, and behavioural versus traditional strategies were compared using the Wilcoxon signed-rank test. Results Behavioural strategies were perceived as more impactful than traditional approaches. Peer comparison through league tables and EHR decision prompts both received high ratings (median 4.0 [IQR 3.0–5.0]). Traditional incentives, encompassing financial, administrative, and informational levers, were rated lower at 2.5 [1.5–3.0] (p<0.001). Participants' ratings aligned with behavioural economic concepts, suggesting that strategies targeting cognitive biases and social norms may be better suited to address referral barriers than conventional measures alone. Conclusion In a pilot survey across Europe, cardiologists viewed behavioural incentives, particularly social comparison and choice-architecture redesign, as more promising than existing traditional measures for enhancing CRT referral patterns. By addressing behavioural barriers and decision heuristics that underpin low CRT uptake, these approaches may support more consistent guideline-aligned care and potentially improve outcomes for heart failure patients.