June 27, 2019
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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.