An electronic health record (EHR)-based nudge significantly reduced rates of low-value axillary surgery in older women with early-stage, clinically node–negative, hormone receptor–positive, HER2-negative breast cancer, according to a nonrandomized controlled trial published in JAMA Surgery.
Researchers at the University of Pittsburgh deployed a nudge in the EHR schedule, identifying patients meeting Choosing Wisely criteria for potential sentinel lymph node biopsy (SLNB) omission. The 2-year study included a 12-month pre-intervention control period and a 12-month intervention period with the EHR nudge.
The rate of SLNB decreased from 46.9% in the control period to 23.8% in the intervention period, a 49.3% reduction (95% confidence interval [CI], −32.9 to −13.8 percentage points). An adjusted interrupted time series model showed the nudge was associated with a significant decrease in SLNB use (adjusted odds ratio, 0.26; 95% CI, 0.07-0.90; P = .03).
"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," wrote the investigators.
The study included 387 patients, with similar characteristics between the control (n=194) and intervention (n=193) groups. Median age was 75 years in both periods. The study found no difference in adjuvant therapy recommendations between the control and intervention periods.
In semistructured interviews, the seven participating surgeons reported the nudge reminded them to consider SLNB omission, standardized their approach, and prompted them to focus more on tumor biology. They rated the intervention highly for acceptability, appropriateness, and feasibility.
The authors suggested that this EHR-based intervention could potentially be useful for reducing low-value care in other settings or populations. They noted the SOUND trial recently showed clinically node-negative patients with small estrogen receptor–positive breast tumors may forgo axillary surgery, regardless of age.
Conflict of interest disclosures are available in the study.