Nudging Clinicians Toward Higher-Value Cancer Care

For patients with breast, lung, and prostate cancer with bone metastases, clinicians face a decision between two therapies of comparable effectiveness but dramatically different cost. Guidelines endorse the use of either zoledronate or denosumab, bone-modifying agents that protect against skeletal complications. But zoledronate costs as little as $215 a year while denosumab costs as much as $26,000 a year.

To conduct our study, we took advantage of concurrent quality improvement nudges at 2 of 7 practice sites within University of Pennsylvania Health System. At Site A, the main cancer center, clinical leadership endorsed zoledronate (over denosumab) and presented performance feedback at quarterly meetings and via email. Site B, a community affiliate, implemented these same nudges and additionally accountable justification, in which clinicians had to justify denosumab prescription to the pharmacy. Using a quasi-experimental design, we examined the effects of these increasingly potent behavioral nudges on zoledronate prescription. Compared to five other usual care sites serving collectively as control, the two sites implementing nudges achieved dramatically higher rates of zoledronate prescription: Site A saw a 26 percentage point increase, and site B a 44.9 percentage point increase, in predicted rates of zoledronate prescription. The Figure below shows unadjusted zoledronate (vs denosumab) prescription rates over the study period.