Background: Inappropriate prescribing behaviour, particularly with antibiotics and opioids, contributes substantially to antibiotic resistance, opioid dependence and rising healthcare costs. Despite available guidelines, a gap exists between evidence-based knowledge and actual prescribing practices. Nudging interventions promise to optimise prescribing decisions without prohibitions or financial incentives. This systematic review examines the effectiveness of nudging interventions for optimising prescribing and assesses their feasibility in the Austrian healthcare system.

Methods: Based on a preliminary search for systematic reviews in MEDLINE, an updated systematic search for randomised controlled trials (RCTs) was conducted across four databases, supplemented by a review of reference lists, yielding 1,447 primary studies after duplicate removal. Three categorisation systems identified through manual research were used to classify the nudges: the Nudge Intervention Ladder (categorisation by degree of intensity), the Theoretical Domains Framework (TDF, categorisation by factors of behavioural change), and the MINDSPACE Framework (categorisation by behavioural factors). Feasibility was assessed through expert consultation using an online questionnaire.

Results: Low-intensity nudges, especially peer comparison interventions, proved effective across all medication groups. The effectiveness of medium- and high-intensity nudges, on the other hand, varied. The limited safety data (n=4) showed no evidence of adverse effects on patient safety. Sparse economic data (n=3) showed no apparent cost-effectiveness. Austrian experts identified key implementation barriers: insufficient system integration, lack of technical infrastructure, data protection concerns, limited resources for IT development, and reservations regarding medical autonomy. Technical system interfaces, adequate funding, pilot projects with accompanying evaluation, and the participatory involvement of physicians and social insurance providers were cited as essential prerequisites.

Discussion: The transferability of nudges, deemed effective to the Austrian context, is limited. Significant barriers include structural differences in IT infrastructure and in the organisation of the healthcare system. Systematic evaluations of safety-related and economic outcomes of implementation are largely lacking, which limits the overall assessment of the interventions. In addition, ethical questions regarding the compatibility of nudging approaches with medical autonomy and informed decision-making require further discussion in health policy.

Conclusion: Nudging interventions show potential to optimise prescribing, with peer-comparison approaches providing the most robust evidence. Significant technical, organisational and financial requirements must be met for implementation in Austria. A step-by-step approach seems advisable: first, pilot projects in defined settings (e.g. specific health insurance contracts) with accompanying evaluation, the development of compatible feedback systems, and the participatory involvement of relevant stakeholders. A broader health policy discussion on goals, ethical limits and desired prescribing patterns should precede implementation measures.