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

Opportunity

There are several ways to position and align patients so that radiation therapy is focused on the cancer target. Daily x-rays are one method, but national guidelines recommend this is not appropriate for patients with advanced cancer receiving palliative therapy. We found nearly 80% of patients were getting daily x-rays when guidelines recommended they should be getting just one x-ray weekly, 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 then subsequently implemented the change at other locations in a step-wedge fashion.

Impact

This trial included over 1000 patients seen by 21 radiation oncologists at 5 practice sites in Pennsylvania and New Jersey. The default intervention was implemented in the EHR within a few minutes and at no cost. Before the intervention, 68.2% of patients received daily imaging. After the intervention, this rate was cut in half to 32.4%.  These findings were similar across both university and community practices. Since we used a stepped-wedge design, this change has been implemented in all radiation oncology practices at Penn Medicine.  Our findings suggest that simple nudges, such as setting default orders, can meaningfully reduce unnecessary care. 

Collaborators

Department of Radiation Oncology, University of Pennsylvania Health System

Unadjusted trends in daily imaging during palliative radiotherapy
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