Using default options to decrease unnecessary imaging for palliative cancer patients receiving radiation therapy

Opportunity

Daily x-rays can be used to focus radiation on a cancer target. However, national guidelines advise against them for patients with advanced cancer receiving palliative therapy. 

Through exploration at Penn Medicine, we found that nearly 80 percent of patients who should be getting weekly x-rays according to national guidelines were getting daily x-rays instead. This was contributing to unnecessarily longer treatment time for patients and thousands of unnecessary x-rays per year.

Approach

We worked with the Department of Radiation Oncology at Penn Medicine to evaluate the decision-making process. We then introduced a default in the electronic health record (EHR) to order weekly x-rays rather than daily x-rays. We randomly selected sites to implement the change and subsequently implemented the change at other locations in a step-wedge fashion. This trial included over 1,000 patients seen by 21 radiation oncologists at five practice sites in Pennsylvania and New Jersey.

Impact

The default intervention was implemented in the EHR within a few minutes at no cost. Before the intervention, 68.2 percent of patients received daily imaging. After the intervention, this rate was cut in half to 32.4 percent. The outcomes were similar across both university and community practices. Our findings suggest that simple nudges, such as setting default orders, can meaningfully reduce unnecessary care.  This default intervention has been implemented in all radiation oncology practices at Penn Medicine. 

Collaborators

Department of Radiation Oncology, Penn Medicine

Unadjusted trends in daily imaging during palliative radiotherapy