In a new study published in JAMA Oncology, my colleagues and I find that behavioral nudges can promote high-value, evidence-based prescribing of specialty drugs in 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.

National guidelines identify hundreds of evidence-based cancer therapies, which often vary considerably in cost but yield similar outcomes. As a result, clinicians and patients frequently confront treatment decisions where one alternative affords significantly higher value than another. The stakes are particularly high in cancer care, where spending will exceed $150 billion in 2020, driven in large part by cancer drug prescribing. This study suggests an effective strategy for nudging clinicians towards higher-value cancer care. 

Samuel Takvorian is an instructor in the Division of Hematology and Oncology at Penn’s Perelman School of Medicine, and an LDI Associate Fellow. The study, “Association of Behavioral Nudges With High-Value Evidence-Based Prescribing in Oncology” was authored by Samuel U. Takvorian, MD, MS; Vrushabh P. Ladage, MHCI; E. Paul Wileyto, PhD; Drew S. Mace, PharmD; Rinad S. Beidas, PhD; Lawrence N. Shulman, MD; and Justin E. Bekelman, MD and appeared in JAMA Oncology on April 30, 2020.