Electronic Health Record-Based Nudge Intervention and Axillary Surgery in Older Women With Breast Cancer: A Nonrandomized Controlled Trial

Abstract

Importance: Choosing Wisely recommendations advocate against routine use of axillary staging in older women with early-stage, clinically node-negative (cN0), hormone receptor-positive (HR+), and HER2-negative breast cancer. However, rates of sentinel lymph node biopsy (SLNB) in this population remain persistently high.

Objective: To evaluate whether an electronic health record (EHR)-based nudge intervention targeting surgeons in their first outpatient visit with patients meeting Choosing Wisely criteria decreases rates of SLNB.

Design, setting, and participants: This nonrandomized controlled trial was a hybrid type 1 effectiveness-implementation study with subsequent postintervention semistructured interviews and lasted from October 2021 to October 2023. Data came from EHRs at 8 outpatient clinics within an integrated health care system; participants included 7 breast surgical oncologists. Data were collected for female patients meeting Choosing Wisely criteria for omission of SLNB (aged ≥70 years with cT1 and cT2, cN0, HR+/HER2- breast cancer). The study included a 12-month preintervention control period; baseline surveys assessing perceived acceptability, appropriateness, and feasibility of the designed intervention; and a 12-month intervention period.

Intervention: A column nudge was embedded into the surgeon's schedule in the EHR identifying patients meeting Choosing Wisely criteria for potential SLNB omission.

Main outcomes and measures: The primary outcome was rate of SLNB following nudge deployment into the EHR.

Results: Similar baseline demographic and tumor characteristics were observed before (control period, n = 194) and after (intervention period, n = 193) nudge deployment. Patients in both the control and intervention period had a median (IQR) age of 75 (72-79) years. Compared with the control period, unadjusted rates of SLNB decreased by 23.1 percentage points (46.9% SLNB rate prenudge to 23.8% after; 95% CI, -32.9 to -13.8) in the intervention period. An interrupted time series model showed a reduction in the rate of SLNB following nudge deployment (adjusted odds ratio, 0.26; 95% CI, 0.07 to 0.90; P = .03). The participating surgeons scored the intervention highly on acceptability, appropriateness, and feasibility. Dominant themes from semistructured interviews indicated that the intervention helped remind the surgeons of potential Choosing Wisely applicability without the need for additional clicks or actions on the day of the patient visit, which facilitated use.

Conclusions and relevance: This study showed that a nudge intervention in the EHR significantly decreased low-value axillary surgery in older women with early-stage, cN0, HR+/HER2- breast cancer. This user-friendly and easily implementable EHR-based intervention could be a beneficial approach for decreasing low-value care in other practice settings or patient populations.

Trial registration: ClinicalTrials.gov Identifier: NCT06006910.

Figure 1.. Schematic of the Study Design and CONSORT Diagram

This 2-year study consisted of a 12-month control period (without the nudge deployed in the electronic health record [EHR]) followed by a 12-month intervention period (with the nudge deployed in the EHR). In between those periods, the study investigator gave a brief introductory session and the surgeons completed a preintervention survey.

Figure 2.. Rates of Sentinel Lymph Node Biopsy (SLNB) Use Before and After Nudge Intervention Deployment in the Electronic Health Record (EHR)

A, Rate of SLNB in the control period and intervention period per month over the 24-month study period with the horizontal dashed line indicating the mean rate of SLNB use over the 12-month period; the bar graph shows the mean (SD) SLNB rates in the respective period with a 49.3% decrease in SLNB usage after deployment of the intervention. B, Breakdown of the rate of SLNB per month across the study period plotted with the number of unique patients seen in a given month. Dotted line between months 12 and 13 in both panels denotes the time at which the nudge intervention was deployed into the EHR.

Figure 3.. Preintervention Survey Results

Results from the preintervention survey, which included (A) a validated survey mechanism about the acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM), which uses an aggregated score within each measure (out of 20, with scores >16 indicating that the designed intervention was acceptable, appropriate, and feasible). Plotted bar indicates median score; error bars, 95% CI; circles, individual surgeon scores. B, Study-specific survey questions asking the surgeons which factors most influenced their decision-making about performing SLNB; higher scores on the 100-point sliding scale indicated the given item highly influenced their practice. Solid line indicates median score; dashed line, IQR; circles, individual surgeon scores.