Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke

Abstract

PURPOSE Few cancer centers systematically engage patients with evidence-based tobacco treatment despite its positive effect on quality of life and survival. Implementation strategies directed at patients, clinicians, or both may increase tobacco use treatment (TUT) within oncology. METHODS We conducted a four-arm cluster-randomized pragmatic trial across 11 clinical sites comparing the effect of strategies informed by behavioral economics on TUT engagement during oncology encounters with cancer patients. We delivered electronic health record (EHR)–based nudges promoting TUT across four nudge conditions: patient only, clinician only, patient and clinician, or usual care. Nudges were designed to counteract cognitive biases that reduce TUT engagement. The primary outcome was TUT penetration, defined as the proportion of patients with documented TUT referral or a medication prescription in the EHR. Generalized estimating equations were used to estimate the parameters of a linear model. RESULTS From June 2021 to July 2022, we randomly assigned 246 clinicians in 95 clusters, and collected TUT penetration data from their encounters with 2,146 eligible patients who smoke receiving oncologic care. Intent-to-treat (ITT) analysis showed that the clinician nudge led to a significant increase in TUT penetration versus usual care (35.6% v 13.5%; OR = 3.64; 95% CI, 2.52 to 5.24; P < .0001). Completer-only analysis (N = 1,795) showed similar impact (37.7% clinician nudge v 13.5% usual care; OR = 3.77; 95% CI, 2.73 to 5.19; P < .0001). Clinician type affected TUT penetration, with physicians less likely to provide TUT than advanced practice providers (ITT OR = 0.67; 95% CI, 0.51 to 0.88; P = .004). CONCLUSION EHR nudges, informed by behavioral economics and aimed at oncology clinicians, appear to substantially increase TUT penetration. Adding patient nudges to the implementation strategy did not affect TUT penetration rates.

Protocol to evaluate sequential electronic health record-based strategies to increase genetic testing for breast and ovarian cancer risk across diverse patient populations in gynecology practices

“…This study will sequentially test the effects of patient-directed strategies, sent via the patient portal and text message, and EHR-based clinician-directed strategies, sent as “pend and send” default orders, on genetic counseling engagement in gynecology practices at two distinct Penn Medicine clinics. It builds upon Penn ISC3’s prior work [ 74 , 75 ] implementing nudges to patients and clinicians by extending it to new populations who face additional barriers to engaging in evidence-based clinical practices. Sequential delivery mechanisms can reinforce the additive value of combining outreach via different communication channels, as well as facilitate comparisons between different patient outreach mechanisms.…”

“…As a project led by the National Cancer Institute-funded Penn Implementation Science Center in Cancer Control (Penn ISC3; P50CA244690), this study builds on strategies from the center’s prior research [ 74 , 75 ]. As in prior studies, RCAs to quickly learn and innovate from pilot tests [ 41 , 76 – 78 ] were used to de-risk and optimize our nudges as implementation strategies.…”

Family cascade screening for equitable identification of familial hypercholesterolemia: study protocol for a hybrid effectiveness-implementation type III randomized controlled trial

“…Bounded rationality leads individuals to rely on common heuristics and biases such as ease of choice when making decisions [17,18]. The incorporation of insights from behavioral economics in other areas of healthcare has led to strong results with respect to supporting clinician and patient behavior towards more evidence-based care [19][20][21][22][23][24]. We leverage these insights in the present study to bolster our implementation strategies and maximize their chance for success.…”