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Default order in EMR reduces unnecessary imaging for patients with advanced cancer
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Introducing a default physician order into electronic medical records significantly reduced unnecessary daily imaging during palliative radiotherapy among adults with advanced cancer, according to results of a randomized study published in JAMA Oncology.
“We recognized that patients were undergoing unnecessary scans due to the standard care habits, and we understood that this frequent imaging was causing more discomfort than benefit,” Sonam Sharma, MD, assistant professor of radiation oncology at Icahn School of Medicine at Mount Sinai, who conducted this research while at Perelman School of Medicine at University of Pennsylvania, said in a press release. “This shows that a minor adjustment can have a dramatic effect on medical practice.”
Each year, about 250,000 patients with advanced cancer in the United States receive palliative radiotherapy to help reduce pain or control bleeding.
Daily imaging, which is used for curative radiotherapy, is unnecessary for palliative radiotherapy, according to national guidelines. It also can increase overall treatment time and expense.
Sharma and colleagues conducted a stepped-wedge cluster randomized clinical trial to test the efficacy of a default imaging order they designed within the EMR that called for no daily imaging during palliative radiotherapy.
The sample included 21 radiation oncologists at five different practices (one university, four community) who prescribed at least 10 courses of palliative radiotherapy between February 2016 and February 2018, including a 1-year preintervention period. Researchers randomly assigned practices to cross over to the intervention in two 4-month periods, and they allowed physicians to opt out and proceed with daily imaging.
The radiation oncologists treated 1,019 patients aged 18 years or older who received 1,188 palliative radiotherapy courses (university practice, n = 747; community-based practices, n = 441) to bone (52.2%), soft tissue (19.9%), brain (15.7%) or multiple sites (12.3%).
The rate of radiotherapy courses with daily imaging served as the primary endpoint.
Results showed that daily imaging decreased from occurring with 68.2% of radiotherapy courses in the preintervention period to 32.4% of courses during the intervention period (adjusted OR = 0.43; 95% CI, 0.24-0.77). Forgoing daily imaging also reduced the 10- to 15-minute length of radiotherapy sessions by an average of 2 minutes per session.
“Nudges can be very powerful. Most previous interventions have been focused on increasing high-value care, such as boosting flu vaccination rates,” Mitesh Patel, MD, MBA, director of the Penn Medicine Nudge Unit and assistant professor of medicine and health care management at Perelman School of Medicine at University of Pennsylvania, said in the release. “This is one of the first cases where we applied a nudge to decrease a lower-value, unnecessary behavior. It not only worked, but its effect has been sustained and implemented throughout our entire health system.” – by John DeRosier
Disclosures: NCI and University of Pennsylvania Health System funded this study. Sharma reports no relevant financial disclosures. Patel reports stock ownership in Catalyst Health and advisory roles with HealthMine Services Holistic Industries and Life.io. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Lanea Keller, MD
Because radiotherapy is often used to palliate symptoms associated with advanced cancer, radiation oncologists frequently encounter palliative scenarios whether they practice in an academic or community setting. Routine use of image guidance in the modern era has helped more precisely target regions at risk, avoid adjacent normal structures and safely escalate dose. Image guidance is usually coupled with advanced treatment planning and delivery such as intensity-modulated radiotherapy, which is characterized by conformal dose distributions requiring precise and accurate patient positioning. In these settings, the intent of the course is usually curative. Generally speaking, daily imaging may be unnecessary in the palliative setting because treatment fields are typically large and overall doses are usually low compared with curative scenarios.
In this interesting study, Sharma and colleagues investigated whether a default order, specifying omission of daily imaging for multifraction palliative radiotherapy courses, would result in decreased use of daily imaging in both the academic and community practice settings. The study allowed physicians to maintain autonomy with the ability to override the order ostensibly according to their clinical assessment, treatment planning and/or technical concerns.
Analysis of the data in this study revealed that the default order resulted in a reduced frequency of daily imaging for palliative cases, from approximately 70% to 30%, as a whole. Researchers also observed a reduction in the frequency of imaging when examining the academic and community subgroups individually.
Eliminating unnecessary routine daily imaging in the palliative setting can decrease the “time on the table” for our patients, some of whom may be extremely uncomfortable, and save health care resources. This study suggests that a default order omitting daily imaging for multifraction palliative courses, with the ability of the physician to override the order on a case-by-case basis, is a clever way to shape clinical behavior and reduce unnecessary care by a “simple nudge.”
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