Date of Award

January 2018

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Kerin B. Adelson


As part of the Choosing Wisely initiative to decrease low-value healthcare spending, the American Society of Clinical Oncology (ASCO) recommends against ordering PET, CT, or bone scan as part of the initial staging workup for patients with early stage breast cancer. Our two-step quality improvement project targeted to increase adherence with this guideline included in-person provider education on breast cancer imaging recommendations followed by the implementation of an electronic decision support tool (best practice advisory or BPA) in our electronic health record system. To assess impact, we compared imaging ordered for stage I/II breast cancer patients who did not receive neoadjuvant therapy and were treated in the Smilow Cancer Hospital/Yale Cancer Center health system during a pre-intervention (diagnosed 7/1/14-6/30/15) and post-intervention period (diagnosed 1/1/16-12/31/16). Cancer stage was obtained through the Yale Tumor Registry, and imaging utilization was measured for each patient during the 90-day period following diagnostic biopsy. We identified 748 women in the pre- and 764 women in the post-intervention period with stage I/II breast cancer. After the intervention, the percentage of patients for whom at least one advanced imaging test was ordered decreased from 17.2% to 13.7%. This decrease approached but did not achieve statistical significance, p = 0.060. The average number of scans ordered per patient among patients for whom imaging was ordered decreased from 1.92 (SD 0.97) to 1.70 (SD 0.71), p = 0.049. The average number of CTs ordered for patients for whom at least one CT was ordered decreased from 1.24 (SD 0.61) to 1.05 (0.22), p = 0.005. In conclusion, while the post-intervention period showed a trend toward less imaging utilization, future work will aim to identify and address remaining barriers to guideline adherence.


This thesis is restricted to Yale network users only. It will be made publicly available on 06/25/2100