A study conducted by Priscilla F. McAuliffe, MD, PhD, and colleagues from the University of Pittsburgh School of Medicine, published in JAMA Surgery, demonstrated the effectiveness of a “nudge” intervention in electronic health records (EHR) to reduce rates of low-value axillary surgery in older women with early-stage, clinically node-negative breast cancer.
The nonrandomized controlled trial involved nearly 400 patients with hormone receptor (HR)-positive/HER2-negative breast cancer. During the control period, sentinel lymph node biopsy (SLNB) was performed in 46.9% of patients, compared to 23.8% during the intervention period. McAuliffe et al. utilized an adjusted interrupted time series model, revealing a significant reduction in SLNB rates following the implementation of the nudge (adjusted odds ratio 0.26, 95% CI 0.07-0.90, P=0.03).
Furthermore, the authors observed sustained effects of the intervention, with SLNB rates continuing to decrease during additional follow-up after the intervention period, maintaining a 6-month mean of 15.6%. They emphasized the durability and potential applicability of this EHR-based intervention in reducing unnecessary surgeries and overtreatment across different healthcare settings and patient populations.
Despite guidelines recommending against routine SLNB in certain older patient groups, the study highlighted persistent high rates of SLNB in practice, which the intervention effectively addressed. McAuliffe and colleagues noted that factors such as tumor biology influenced surgeon decision-making during the intervention period, potentially explaining variations in SLNB rates.
The study, conducted in an academic health system, received praise for its minimal burden on surgeons while calling for context-specific adaptations to facilitate broader implementation in decentralized healthcare settings. The commentary accompanying the study emphasized the importance of interdisciplinary collaboration to optimize treatment decisions and mitigate implementation barriers in varied healthcare systems.
Limitations acknowledged by the researchers included the nonrandomized study design and the potential for alternative explanations contributing to the observed reduction in SLNB rates. The study’s findings underscored the promising role of EHR-based nudges in promoting evidence-based practice and reducing unnecessary healthcare interventions.
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