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Randomized Controlled Trial
. 2023 Oct 1;41(28):4511-4521.
doi: 10.1200/JCO.23.00355. Epub 2023 Jul 19.

Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke

Brian P Jenssen  1 , Robert Schnoll  2   3 , Rinad S Beidas  4   5 , Justin Bekelman  6 , Anna-Marika Bauer  2 , Sarah Evers-Casey  7 , Tierney Fisher  7 , Callie Scott  3 , Jody Nicoloso  7 , Peter Gabriel  3 , David A Asch  4 , Alison M Buttenheim  8 , Jessica Chen  4 , Julissa Melo  4 , Dwayne Grant  9 , Michael Horst  9 , Randall Oyer  9 , Lawrence N Shulman  3 , Alicia B W Clifton  3 , Adina Lieberman  4 , Tasnim Salam  4 , Katharine A Rendle  10   11 , Krisda H Chaiyachati  4   12 , Rachel C Shelton  13 , Oluwadamilola Fayanju  14 , E Paul Wileyto  11 , Sue Ware  2 , Daniel Blumenthal  2 , Daniel Ragusano  4 , Frank T Leone  15
Affiliations
Randomized Controlled Trial

Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke

Brian P Jenssen et al. J Clin Oncol. .

Abstract

Purpose: Few cancer centers systematically engage patients with evidence-based tobacco treatment despite its positive effect on quality of life and survival. Implementation strategies directed at patients, clinicians, or both may increase tobacco use treatment (TUT) within oncology.

Methods: We conducted a four-arm cluster-randomized pragmatic trial across 11 clinical sites comparing the effect of strategies informed by behavioral economics on TUT engagement during oncology encounters with cancer patients. We delivered electronic health record (EHR)-based nudges promoting TUT across four nudge conditions: patient only, clinician only, patient and clinician, or usual care. Nudges were designed to counteract cognitive biases that reduce TUT engagement. The primary outcome was TUT penetration, defined as the proportion of patients with documented TUT referral or a medication prescription in the EHR. Generalized estimating equations were used to estimate the parameters of a linear model.

Results: From June 2021 to July 2022, we randomly assigned 246 clinicians in 95 clusters, and collected TUT penetration data from their encounters with 2,146 eligible patients who smoke receiving oncologic care. Intent-to-treat (ITT) analysis showed that the clinician nudge led to a significant increase in TUT penetration versus usual care (35.6% v 13.5%; OR = 3.64; 95% CI, 2.52 to 5.24; P < .0001). Completer-only analysis (N = 1,795) showed similar impact (37.7% clinician nudge v 13.5% usual care; OR = 3.77; 95% CI, 2.73 to 5.19; P < .0001). Clinician type affected TUT penetration, with physicians less likely to provide TUT than advanced practice providers (ITT OR = 0.67; 95% CI, 0.51 to 0.88; P = .004).

Conclusion: EHR nudges, informed by behavioral economics and aimed at oncology clinicians, appear to substantially increase TUT penetration. Adding patient nudges to the implementation strategy did not affect TUT penetration rates.

Trial registration: ClinicalTrials.gov NCT04737031.

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Conflict of interest statement

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Rinad S. Beiads

Honoraria: Optum/UnitedHealth Group

Consulting or Advisory Role: OptumLabs, Optum/UnitedHealth Group

Justin Bekelman

Stock and Other Ownership Interests: Reimagine Care

Honoraria: National Comprehensive Cancer Network

Consulting or Advisory Role: UnitedHealthcare, Reimagine Care, AstraZeneca, Healthcare Foundry

Research Funding: Loxo@Lilly (Inst), Gilead Sciences (Inst)

Patents, Royalties, Other Intellectual Property: Patent pending: machine learning systems using electronic health record data and patient-reported outcomes; 17/972,105

Callie Scott

Employment: Cohere Health, Humana

David A. Asch

Employment: VAL Health

Leadership: VAL Health

Stock and Other Ownership Interests: VAL Health

Honoraria: Deloitte, Boehringer Ingelheim, Mars Veterinary Health

Research Funding: United Health Group (Inst)

Jessica Chen

Employment: University of Pennsylvania

Lawrence N. Shulman

Consulting or Advisory Role: Genentech

Research Funding: Celgene (Inst), Independence Blue Cross (Inst)

Katharine A. Rendle

Honoraria: MJH Healthcare Holdings, LLC

Consulting or Advisory Role: Merck

Research Funding: Pfizer (Inst), AstraZeneca

Travel, Accommodations, Expenses: MJH Healthcare Holdings, LLC

Krisda H. Chaiyachati

Employment: Penn Medicine, Verily, The Children's Hospital of Philadelphia

Leadership: Intend Health Strategies

Stock and Other Ownership Interests: Verily

Travel, Accommodations, Expenses: The American Telemedicine Association

Oluwadamilola Fayanju

Research Funding: Gilead Sciences

No other potential conflicts of interest were reported.

Figures

FIG 1.
FIG 1.
CONSORT diagram. For the assigned to usual care arm, treatment visit = 0 because of the nature of the intervention design. There are no nudges to be delivered. In other words, treatment is completed with the engaged visit, and there are no additional treatment visits. ITT, intent-to-treat.
FIG 2.
FIG 2.
Rates of tobacco treatment engagement across treatment arms (ITT model). ITT, intent-to-treat.
See this image and copyright information in PMC

References

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