Electronic health record-based messages delivered solely to clinicians increased referral to tobacco use treatment for cancer patients who smoke, according to a recent study published in the Journal of Clinical Oncology.
“The motivation behind this study is to close the gap between what we know and what we do in oncology care related to an evidence-based practice: tobacco cessation treatment,” Rinad Beidas, PhD, the chair and Ralph Seal Paffenbarger Professor of Medical Social Sciences and a co-author of the study.
More than 50 percent of patients who smoke prior to a cancer diagnosis continue to smoke after their diagnosis, which can decrease quality of life and survival. Evidence-based tobacco use treatment can help these individuals stop smoking, but only half of cancer centers consistently identify patient tobacco use, and even fewer systematically engage patients in evidence-based practices around tobacco cessation, according to recent data.
In the current study, investigators delivered electronic health record (EHR)-based “nudges,” or messages promoting tobacco use treatment, either to clinicians alone, only patients, both groups, or neither group. More than 240 oncology clinicians and more than 2,146 patients who smoke and were receiving cancer care from 11 clinical sites within the Penn Medicine system were included in the analysis.
Nudges were specifically designed to counteract cognitive biases that reduce engagement in tobacco use treatment, with the goal of helping investigators determine which approach would result in the highest rates of referral to evidence-based tobacco cessation treatment amongst patients, according to Beidas.
“We were interested in applying insights from behavioral economics, which helps us understand how and why people behave and make decisions,” said Beidas, who is also a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.
Overall, nudges made to just clinicians led to a significant increase in referral to tobacco use treatment versus usual care; 35.6 percent and 13.5 percent, respectively. Nudges made to patients, however, did not significantly increase referral to tobacco use treatment.
“Our clinician nudge, which was designed to remind clinicians that ‘treating tobacco dependence without delay can improve cancer care outcomes,’ facilitating an instant referral to evidence-based tobacco cessation care, and requiring written justification for not selecting the referral, yielded increased odds of referral compared to usual care. This nudge leveraged omission bias, or the tendency to focus on the potential harm or action more than that of inaction, default options, and accountable justification of not engaging in the desired behavior (referring to evidence-based tobacco cessation),” Beidas said.
Beidas said the results demonstrate that the approach can be implemented into cancer centers across the country, while further study is needed to better understand how effectively the approach is implemented across different cancer care settings.
“We are interested in studying scale-up of this approach nationally, further optimizing the design of the patient nudge, which was less successful, and understanding the sustainability of this approach on continued physician behavior change. There is also room for improvement in increasing referral rates, and we can test additional multi-level strategies to close the gap between what we know and do for tobacco cessation in patients receiving cancer care,” Beidas said.
Brian Jenssen, MD, MSHP, assistant professor of Pediatrics at the University of Pennsylvania Perelman School of Medicine, and Frank Leone, MD, MS, professor of Medicine in the Divisions of Pulmonary and Allergy and Critical Care at the Perelman School of Medicine, were lead authors of the study. Additional co-authors include Robert Schnoll, PhD, professor of Psychiatry at the Perelman School of Medicine, and Justin Bekelman, MD, professor of Radiation Oncology, of Medicine, and of Medical Ethics and Health Policy at the Perelman School of Medicine.
This work was supported by a National Cancer Institute grant P50 CA244690.
