Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke

Protocol for a type 3 hybrid implementation cluster randomized clinical trial to evaluate the effect of patient and clinician nudges to advance the use of genomic medicine across a diverse health system

BACKGROUND

Germline genetic testing is recommended for an increasing number of conditions with underlying genetic etiologies, the results of which impact medical management. However, genetic testing is underutilized in clinics due to system, clinician, and patient level barriers. Behavioral economics provides a framework to create implementation strategies, such as nudges, to address these multi-level barriers and increase the uptake of genetic testing for conditions where the results impact medical management.

METHODS

Patients meeting eligibility for germline genetic testing for a group of conditions will be identified using electronic phenotyping algorithms. A pragmatic, type 3 hybrid cluster randomization study will test nudges to patients and/or clinicians, or neither. Clinicians who receive nudges will be prompted to either refer their patient to genetics or order genetic testing themselves. We will use rapid cycle approaches informed by clinician and patient experiences, health equity, and behavioral economics to optimize these nudges before trial initiation. The primary implementation outcome is uptake of germline genetic testing for the pre-selected health conditions. Patient data collected through the electronic health record (e.g. demographics, geocoded address) will be examined as moderators of the effect of nudges.

DISCUSSION

This study will be one of the first randomized trials to examine the effects of patient- and clinician-directed nudges informed by behavioral economics on uptake of genetic testing. The pragmatic design will facilitate a large and diverse patient sample, allow for the assessment of genetic testing uptake, and provide comparison of the effect of different nudge combinations. This trial also involves optimization of patient identification, test selection, ordering, and result reporting in an electronic health record-based infrastructure to further address clinician-level barriers to utilizing genomic medicine. The findings may help determine the impact of low-cost, sustainable implementation strategies that can be integrated into health care systems to improve the use of genomic medicine.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT06377033. Registered on March 31, 2024. https://clinicaltrials.gov/study/NCT06377033?term=NCT06377033&rank=1.

Nudging oral habits; application of behavioral economics in oral health promotion: a critical review

Background

Oral health disorders significantly contribute to the global incidence of chronic diseases. Nudge interventions have demonstrated effectiveness in enhancing people's decision-making and self-management capacities in a cost-efficient manner. As a result, these interventions could be valuable tools for fostering improved oral care habits. This critical review explores potential behavioral nudges applicable to promoting oral health.

Methods

A thorough electronic literature search was conducted on Scopus, Embase, and PubMed databases for papers published post-2008. The search focused on empirical evidence concerning the direct and indirect application of Nudge theory in oral health enhancement. In addition, the investigation included the nudge intervention's role in managing common non-communicable disease risk factors (tobacco, alcohol, and sugar) and their use in other health sectors.

Results and conclusion

There is a dearth of studies on behavioral economics, particularly those involving reward and reminder techniques. However, various successful nudge interventions have been identified in other sectors that aim to improve health decisions. These include strategies encouraging healthier nutritional choices, tobacco and alcohol cessation, medication compliance, routine physical activity, and regular health check-ups. Such interventions can also have direct or indirect positive impacts on oral health. Implementing these interventions within an oral care framework could promote oral health due to similar underlying cognitive mechanisms. However, different types of nudge interventions have varying degrees of effectiveness. Furthermore, factors such as the method of delivery and the characteristics of the targeted population significantly influence the outcome of the intervention. Hence, it is imperative to conduct extensive studies in diverse socioeconomic settings to fully understand the potentials, limitations, and impacts of nudge interventions in promoting oral health.

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

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.

Speeding implementation in cancer: The National Cancer Institute's Implementation Science Centers in Cancer Control

The National Cancer Institute's Implementation Science Centers in Cancer Control (ISC3) Network represents a large-scale initiative to create an infrastructure to support and enable the efficient, effective, and equitable translation of approaches and evidence-based treatments to reduce cancer risk and improve outcomes. This Cancer MoonshotSM-funded ISC3 Network consists of 7 P50 Centers that support and advance the rapid development, testing, and refinement of innovative approaches to implement a range of evidence-based cancer control interventions. The Centers were designed to have research-practice partnerships at their core and to create the opportunity for a series of pilot studies that could explore new and sometimes risky ideas and embed in their infrastructure a 2-way engagement and collaboration essential to stimulating lasting change. ISC3 also seeks to enhance capacity of researchers, practitioners, and communities to apply implementation science approaches, methods, and measures. The Organizing Framework that guides the work of ISC3 highlights a collective set of 3 core areas of collaboration within and among Centers, including to 1) assess and incorporate dynamic, multilevel context; 2) develop and conduct rapid and responsive pilot and methods studies; and 3) build capacity for knowledge development and exchange. Core operating principles that undergird the Framework include open collaboration, consideration of the dynamic context, and engagement of multiple implementation partners to advance pragmatic methods and health equity and facilitate leadership and capacity building across implementation science and cancer control.

Study on the Conduction Analysis and Blocking Intervention Scheme of Emotional Disorders between Cancer Patients and Their Families

Objective

To analyze the transmission and blocking intervention scheme of emotional disorders between cancer patients and their families.

Methods

About 150 patients with cancer and 150 family members with mood disorders treated in a tertiary hospital in North China from March 2021 to Octobor2021 were enrolled. The patients were randomly assigned into control group and study group. The control group received routine intervention, and the study group received the diagnosis, intervention, and treatment strategies of doctor-patient-affective disorder. The factors related to the transmission of emotional disorders between cancer patients and their families were analyzed, and the alterations of anxiety, depression, social support, and satisfaction of the two groups were compared under different blocking intervention schemes.

Results

(1) Univariate analysis indicated that there were significant differences in family age, family income, sex, location of tumor, course of disease, TNM stage, somatic symptoms, and the incidence of anxiety and depression. There exhibited no significant difference between the gender of the family, the years of education of the family, the occupational status of the family, the relationship between the family and the patient, the mode of payment of the patient's medical expenses, the age of the patient, the mode of treatment of the patient, the degree of knowledge of the disease, and the incidence of anxiety and depression (P > 0.05). The anxiety and depression status of relatives were taken as dependent variables, and the age of family members, family income status, sex of patients, location of tumor, course of disease, TNM stage, and physical symptoms of patients were taken as independent variables, and the data were analyzed by Logistic regression analysis. Logistic regression analysis indicated that family income, tumor location, disease course, TNM stage, and somatic symptoms were the risk factors of anxiety and depression in relatives. (2) Comparison of social support status and intergroup, the objective support, subjective support, support utilization, and total score of social support in the study group were higher compared to the control group. In terms of the depression score before intervention, there exhibited no significant difference (P > 0.05), but after intervention, the depression score of the two groups decreased, and the depression score of the study group was lower compared to the control group before intervention, 1 week, 2 weeks, 3 weeks, and 4 weeks after intervention (P < 0.05). In terms of the anxiety score before intervention, there exhibited no significant difference (P > 0.05), but after intervention, the anxiety score of the two groups decreased, and the anxiety score of the study group was lower compared to the control group before intervention, 1 week, 2 weeks, 3 weeks, and 4 weeks after intervention (P < 0.05). Comparison of the satisfaction between the two groups and the study group was very satisfied in 56 cases, satisfactory in 14 cases, and general in 5 cases, and the satisfaction rate was 100.00%. The control group was very satisfied in 35 cases, satisfactory in 23 cases, general in 12 cases, and dissatisfied in 5 cases, and the satisfaction rate was 93.33%. The satisfaction of the study group was higher compared to the control group (P < 0.05).

Conclusion

Family income, tumor location, course of disease, TNM stage, and somatic symptoms are the risk factors of anxiety and depression in relatives. After establishing the diagnosis, intervention and treatment strategies of doctor-patient-affective disorder, the emotional disorder of family members of cancer patients, is significantly promoted, and the intervention satisfaction is high, so the scheme is worth promoting.