“The straightforward, user-friendly nudge supplies a well timed reminder to surgeons to contemplate the worth of SLNB for every affected person,” in keeping with Priscilla McAuliffe, MD, PhD.
An digital well being document (EHR)–primarily based nudge intervention could restrict using low-value sentinel lymph node biopsy (SLNB) amongst older sufferers with early-stage, cN0, hormone receptor (HR)–optimistic, HER2-negative breast most cancers with out impacting receipt of adjuvant therapy, in keeping with findings from a nonrandomized trial (NCT06006910) revealed in JAMA Surgical procedure.1
Investigators administered SLNB to 46.9% (n = 91/194) of sufferers in the course of the management interval and 23.8% (n = 46/193) in the course of the intervention interval through which the nudge was carried out. When stratifying for race or ethnicity, there was no distinction between intervals. When adjusting for secular tendencies in SLNB use, intervention with the nudge correlated with a major discount in using SLNB (adjusted odds ratio [aOR], 0.26; 95% CI, 0.07-0.90; P = .03).
The charges of pathological node positivity have been 8.8% for sufferers handled in the course of the management interval and 15.2% for individuals who obtained therapy in the course of the intervention interval. The decreases in using SLNB with the nudge intervention accompanied a discount within the variety of sufferers with signs warranting a referral for lymphedema analysis. The referral charges have been 6.2% for sufferers in the course of the management interval and three.6% in the course of the intervention interval. Moreover, adjuvant system remedy suggestions didn’t seem to vary between the intervention and management teams.
Throughout the Epic EHR system, a nudge intervention column was carried out into the schedule. This nudge flagged sufferers primarily based on their age, analysis code, and a brand new go to. This was indicated in the course of the first outpatient surgical session by a warning sign or a purple clipboard icon. When the surgeon clicked or hovered over the icon, it had them contemplate the omission of SLNB primarily based on an in depth assessment of a core biopsy and ultrasonographic imaging.
“In breast most cancers, there’s a rising motion towards exactly treating every particular person affected person, [which is] what we name right-sized care. SLNB helps us decide if breast most cancers has unfold to the underarm lymph nodes, nevertheless it’s not essential for each affected person,” senior examine creator Priscilla McAuliffe, MD, PhD, an affiliate professor of surgical procedure on the College of Pittsburgh and a breast surgical oncologist on the College of Pittsburgh Medical Middle (UPMC) Hillman and UPMC Magee-Womens Hospital, stated in a press launch on these findings.2 “The straightforward, user-friendly nudge supplies a well timed reminder to surgeons to contemplate the worth of SLNB for every affected person.”
Investigators carried out this hybrid kind 1 effectiveness-implementation examine to judge the feasibility and utility of an EHR-based nudge to restrict using low-value SLNB.
The trial was carried out from October 2021 to October 2023 as a part of the pre-intervention management interval, through which 194 sufferers obtained therapy with out using the digital nudge. The nudge was deployed from October 2022 to October 2023; 193 sufferers obtained therapy throughout this intervention interval. Investigators collected information primarily based on EHRs at 8 outpatient clinics inside an built-in system that included 7 breast surgical oncologists.
The trial’s major finish level was the speed of SLNB use after the nudge was built-in into the EHR. Secondary finish factors included the acceptability, appropriateness, and feasibility of the nudge intervention utilizing a validated survey instrument.
The median affected person age was 75 years (IQR 72-79) in each the management and intervention teams. Findings confirmed no important variations in tumor traits between these teams.
Survey outcomes indicated that the nudge intervention fulfilled the standards for acceptability, appropriateness, and feasibility among the many responding surgeons; mixture scores exceeded 16 on a 20-point scale. Particularly, the scores for the intervention’s feasibility have been the very best. Moreover, semi-structured interviews among the many surgeons revealed 4 key themes associated to using the nudge, together with the intervention as a “reminder” for affected person applicability of SLNB omission, logistics of the intervention’s implementation and engagement, affected person notion and affect, and impression of axillary staging decision-making.
References
- Carleton N, Radomski TR, Li D, et al. Digital well being document–primarily based nudge intervention and axillary surgical procedure in older girls with breast most cancers: a nonrandomized managed trial. JAMA Surg. Printed on-line July 17, 2024. doi:10.1001/jamasurg.2024.2407
- Digital immediate for surgeons could scale back breast most cancers overtreatment. Information launch. UPMC. July 17, 2024. Accessed July 23, 2024. https://tinyurl.com/5n8hdu5d
