Default orders can help physicians de-implement low-value treatments.
This article was first published on Monday, July 1, 2019 in MedPage Today.
By Ian Ingram, Deputy Managing Editor, MedPage Today.
Adding a default order to the electronic health record (EHR) halved the use of unnecessary daily imaging before palliative radiation therapy in advanced cancer patients, a randomized trial found.
Before the EHR "nudge" at five University of Pennsylvania Health System radiation oncology centers, daily imaging was used 68% of the time prior to palliative care. This number dropped to 32% after implementation (adjusted OR 0.43, 95% CI 0.24-0.77), reported Sonam Sharma, MD, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues in JAMA Oncology.
"I was surprised by how quickly these types of nudges can work," Sharma told MedPage Today. "Almost as soon as we implemented the nudge -- very, very quickly thereafter -- we saw large and sustained drops in the number of imaging orders that were used in palliative radiation."
According to background information in the study, it's estimated that about 250,000 patients with advanced cancer receive palliative radiation therapy each year to control pain or bleeding, or improve patients' quality of life. Since 2016, however, national guidelines have recommended for weekly rather than daily imaging in the palliative setting.
Sharma, who took part in the research while at the Perelman School of Medicine at the University of Pennsylvania, said daily imaging, which is required during curative radiation interventions, was being used almost reflexively in the palliative setting as well.
"It was a habit that we identified, and at first struggled in ways at our own clinic to change, until we identified this sort of behavioral economics tool that might be very effective, and proved itself to be very effective at changing that behavior," she said.
Over a 4-month period, a default imaging order in the EHR was added to specify no daily imaging during palliative radiotherapy, first at the university and then in community-based clinics in New Jersey and Pennsylvania. This was "preceded by a department-wide session with intervention group physicians and therapy staff announcing the initiation of the intervention," according to the study's protocol. Physicians retained the option to select a different frequency for imaging.
Similar declines after the nudge versus the pre-intervention period were observed across settings:
- University (67.2% to 28.8%, adjusted OR 0.33, 95% CI 0.14-0.76)
- Community (69.4% to 42.3%, adjusted OR 0.45, 95% CI 0.22-0.89)
Sharma noted that EHR nudges also could improve use of guideline-recommended hypofractionated radiation therapy for common cancers such as breast and prostate, with the potential to standardize care and reduce low-value care.
"It's really hard to change clinical practice, and innovative tools like nudges that are baked into the electronic health record seem not only promising, but now in cancer care have been shown to help physicians practice more patient-centered care," co-author Justin E. Bekelman, MD, director of the Penn Center for Cancer Care Innovation in Philadelphia, told MedPage Today.
He pointed out that the "Choosing Wisely" initiative has targeted low- or no-value healthcare, yet literature has shown that simply giving physicians or patients information on what these are doesn't typically yield change. The findings from the current study could be translatable to other areas of low-value care identified by "Choosing Wisely" and other organizations, he said.
"Not only do we know that nudges can help doctors pick up high-value treatments, but what this shows is that nudges can help doctors de-adopt or de-implement low-value treatments," said Bekelman.
His group's study was a stepped-wedge cluster randomized trial from 2016 to 2018 that involved 21 radiation oncologists who performed at least 10 palliative courses during the trial period. Daily imaging was defined as occurring at least 80% of the time.
In all, 1,019 adults received 1,188 courses of palliative radiation therapy for metastases of the bone, soft tissue, brain, or multiple sites. The bulk of the treatments took place in the academic setting (n=747). Secondary analyses that adjusted for patients' age, sex, race, type of insurance, and other clinical and treatment factors yielded similar findings.
The study was funded, in part, by grants from the National Cancer Institute and the University of Pennsylvania Health System's Penn Medicine Nudge Unit and Department of Radiation Oncology.
Sharma reported no conflicts of interest. Bekelman has served as a consultant for the Centers for Medicare and Medicaid Services. Another co-author reported ownership of Catalyst Health and serving on the advisory boards for Life.io, HealthMine Services, and Holistic Industries.
“Almost as soon as we implemented the nudge -- very, very quickly thereafter -- we saw large and sustained drops in the number of imaging orders that were used in palliative radiation.”
Sonam Sharma, MD, of the Icahn School of Medicine at Mount Sinai
Before the EHR "nudge" at five University of Pennsylvania Health System radiation oncology centers, daily imaging was used 68% of the time prior to palliative care.
Over a 4-month period, a default imaging order in the EHR was added to specify no daily imaging during palliative radiotherapy.
After the 'nudge' the number of daily imaging dropped to 32%.