EHR ‘Nudge’ Cut Low-Value Surgery Rates in Older Breast Cancer Patients

A “nudge” intervention in an electronic health record (EHR) significantly reduced rates of low-value axillary surgery in older women with early-stage, clinically node-negative breast cancer, according to results from a nonrandomized controlled trial.

Among nearly 400 patients with hormone receptor (HR)-positive/HER2-negative breast cancer, sentinel lymph node biopsy (SLNB) was performed in 46.9% of those during the control period and in 23.8% of those in the intervention period, reported Priscilla F. McAuliffe, MD, PhD, of the University of Pittsburgh School of Medicine, and colleagues.

An adjusted interrupted time series model showed a reduction in the rate of SLNB following the nudge (adjusted OR 0.26, 95% CI 0.07-0.90, P=0.03), they wrote in JAMA Surgery.

Additional follow-up after the conclusion of the intervention showed that SLNB rates continued to decrease, with a 6-month mean of 15.6%, indicating that the effect of the intervention was durable, the authors noted.

“A nudge that targets surgeons before counseling patients on surgical management can be used to decrease use of a low-value surgery and reduce overtreatment,” they wrote. “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.”

Using Choosing Wisely criteria, the Society of Surgical Oncology recommends against routine use of SLNB in women ages 70 and older with early-stage, clinically node-negative, HR-positive breast cancer. However, McAuliffe and team pointed out that despite attempts to reduce low-value SLNB, the rates in this population “remain persistently high.”

As for why surgeons continue to perform SLNB, they cited factors related to tumor biology more frequently in the intervention period, such as higher Ki-67, lower estrogen and/or progesterone receptor expression, and tumor grade.

Rates of pathological node positivity were higher in the intervention period (15.2% vs 8.8% in the control period), and all patients with node positivity were staged with pN1 disease. McAuliffe and colleagues also pointed out that the reduction in SLNB use was accompanied by a decrease in the number of patients who were referred for lymphedema evaluation (3.6% in the intervention period vs 6.2% in the control period).

In a commentary accompanying the study, Oluwadamilola M. Fayanju, MD, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues suggested that a strength of the intervention was the low burden of labor placed on surgeons, though they noted that “context-specific adaptations will be required for widespread implementation.”

For example, they pointed out that the study was conducted in an academic health system in which multidisciplinary care and coordination is standard, “allowing for coordinated de-escalation and personalized treatment planning.”

“However, most breast cancer care in the U.S. is decentralized, with surgeons potentially making decisions on inclusion or omission of SLNB without the knowledge or buy-in of the medical and radiation oncologists who will evaluate their patients after surgery,” the editorialists wrote, adding that getting the perspective of nonsurgical physicians could help avoid potential implementation barriers in systems with more decentralized care.

This study was conducted at eight surgical oncology clinics in a single integrated healthcare system, with the pre-intervention control period running October 2021 through October 2022, and the intervention period from October 2022 through October 2023.

The 387 eligible patients had a new consult with a breast surgical oncologist and met the following Choosing Wisely criteria: age ≥70 years and a new diagnosis of HR-positive/HER2-negative, clinically node-negative, early-stage (clinical T stage I and II) breast cancer. Patients in both the control and intervention periods had a median age of 75 years, and there were no significant differences in tumor characteristics.

The nudge intervention consisted of a column added to the EHR that flagged eligible patients, along with a prompt reminding surgeons to consider omission of SLNB after review of core biopsy pathology and ultrasound.

McAuliffe and team acknowledged several limitations to their study, including the possibility that there could have been alternative explanations outside of the intervention for the decrease in SLNB rates, since the study was nonrandomized.

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