A Nudge in the Right Direction With Clinical Prompts

Abstract

Nudges" are structural interventions that prompt decisionmakers to change their behavior and are increasingly used in health care to encourage adherence to evidence-based guidelines and enhance patient outcomes. 1 Carleton and colleagues 2 describe their nonrandomized, hybrid type 1 effectiveness-implementation trial to assess an electronic health record (EHR)-based nudge designed to reduce lowvalue sentinel lymph node biopsy (SLNB) rates in patients meeting the Society of Surgical Oncology's Choosing Wisely Guidelines, which recommend against routine SLNB in women 3 aged 70 years with early-stage, clinically node-negative, hormone receptor-positive breast cancer, 3 although SLNB is still performed in up to 80% of patients who meet these criteria. 4 The nudge consisted of a column added to the EHR that displayed a red flag and associated advisory for eligible patients and prompted surgeons to consider SLNB omission. After nudge deployment, unadjusted SLNB rates decreased by almost half, from 46.9% in the prenudge control group to 23.8% postintervention, with a concomitant decrease in the collective rate of adverse postoperative sequelae. Notably, there were no changes in recommended adjuvant therapy, and lower SLNB rates persisted after trial completion.A major strength of the intervention is the low burden of labor imposed on the individuals (surgeons) at whom it was directed, but context-specific adaptations will be required for widespread implementation. For example, the authors practice in an academic health system in which multidisciplinary