The National Institutes of Health’s Research Spotlights section for July featured work by CHIBE members: Mitesh Patel, MD, MBA, MS; Justin Bekelman, MD; and Dylan Small, PhD. Read the study published in JAMA Oncology here.
“Nudges” to Change Palliative Care
Researchers funded by the NCI and the University of Pennsylvania Health System are making strides in reducing unnecessary medical procedures. In the U.S., approximately 250,000 patients annually with advanced cancer receive palliative radiotherapy to reduce symptoms such as pain or to improve quality of life. Daily imaging is often used in curative radiotherapy to ensure reproducible patient positioning; however, national guidelines recommend transitioning to weekly imaging for palliative radiotherapy since daily imaging unnecessarily increases the time of each session for patients who are often in pain or discomfort. Leveraging insights from the field of behavioral economics, default options have been shown to be able to change physician behavior but have focused more on adoption/implementation of high value care and less on de-adoption of unnecessary care.
The study took place across 5 radiation oncology practices and 21 radiation oncologists from 2016-2018 and included patients (n=1019) undergoing palliative radiotherapy for cancers that had spread to other organs, including bone, soft tissue, and the brain. The researchers conducted a stepped-wedge cluster randomized clinical trial to test the effectiveness of introducing a default imaging order in the electronic health record (EHR) that specified no daily imaging during palliative radiotherapy versus the usual practice. Importantly, physicians could opt out and select another imaging frequency. Groups were randomly assigned to cross over to the intervention in two 4-month predefined wedges (analyses included 1-month washout periods).
The researchers found that adding the new default order “nudge” led to a reduction in daily imaging from 68% of the treatment regimens to 32%. With the reduction in unnecessary daily imaging, the average length of the radiotherapy sessions was reduced. This shows that a relatively simple nudge in the EHR can have a significant effect on medical practice and physician behavior, decreasing the use of unnecessary medical procedures and potentially saving healthcare costs.
Sharma S, Guttmann D, Small DS, Rareshide CAL, Jones J, Patel MS, Bekelman JE. 2019. Effect of Introducing a Default Order in the Electronic Medical Record on Unnecessary Daily Imaging During Palliative Radiotherapy for Adults with Cancer: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Oncol. doi: 10.1001/jamaoncol.2019.1432.