ELECTRONIC health record (EHR)-based prompts, developed by researchers at the University of Pittsburgh and UPMC Hillman Cancer Center, Pennsylvania, USA, have been shown to halve the rate of unnecessary surgery in older patients with early-stage breast cancer.
Rates of sentinel lymph node biopsy (SLNB) in patients aged 70 and over with early-stage, hormone receptor-positive breast cancer are persistently high despite not being advised due to its lack of positive effect on rates of survival. Although efforts to reduce its use were introduced, including surgeon education and predictive tools, many women still undergo SLNB despite it being considered unnecessary or “low-value”.
This new intervention was an EHR prompt, or “nudge”, that flagged eligible patients during their first surgical consultation, reminding surgeons to consider omitting SLNB. The nudge appeared as a caution icon in the EHR schedule view and surgeons received a brief session explaining the notification. While EHR nudges have been effective in other areas, they are rarely used to reduce surgeries.
The group conducted a prospective, nonrandomised controlled trial, over two years starting in October 2021, to investigate whether an EHR nudge could lower the incidence of low-value SLNB use. Their focus was on the intervention’s effectiveness, while also assessing its feasibility, acceptability, and post-intervention impact.
The results showed that SLNB usage dropped from 46.9% (91 of 194 patients) in the control period to 23.8% (46 of 193 patients) in the intervention period, a 49.3% reduction. The adjusted analysis confirmed a significant decrease in SLNB use with a continued decline in rates post-intervention.
Despite its limitations of small sample size and non-randomised design, the study highlights an effective approach to reducing low-value surgeries by focusing on surgeon behaviour. Unlike prior efforts, this intervention provided a continuous, low-burden reminder during clinic visits leading to a significant change in patient treatment pathways.
Katie Wright, EMJ
Reference
Carleton N et al. Electronic health record-based nudge intervention and axillary surgery in older women with breast cancer: a nonrandomized controlled trial. JAMA Surg. 2024;DOI:10.1001/jamasurg.2024.2407.
