VOLUME 34 • NUMBER 16 • JUNE 1, 2016
JOURNAL OF CLINICAL ONCOLOGY
Default Options: Opportunities to Improve Quality
and Value in Oncology
Eric Ojerholm, Scott D. Halpern, and Justin E. Bekelman, University of Pennsylvania, Philadelphia, PA
Default options exert subtle but powerful influences on decision
making. They change behavior in diverse situations, from organ
donation to retirement savings to Internet privacy preferences.1-3
Attention has focused more recently on harnessing their power to
improve medical care. For example, investigators have leveraged
defaults to increase vaccination rates and boost the prescription of
generic medications.4,5 Yet, to our knowledge, these insights have not
been widely applied to cancer care. In this article, we explore what
defaults are, why they work, and how they could be used to improve
quality and value in oncology.
Plainly stated, a default option is that which occurs if no alter-
native choice is made. Could such a simple concept truly influence
meaningful health care decisions? Consider a specific example tested
in real patients.6 Patients with life-limiting illnesses took home an
advance directive that described the options of life-extending care
or comfort-oriented care. Patients were randomly assigned to receive
a form with one option already checked—a default—and were asked
to either confirm this choice or cross it out and select an alternative.
The default significantly influenced the final preference of patients:
comfort-oriented care was chosen by 77% of patients in the comfort-
oriented default group; however, only 43% of patients in the life-
extending default group chose comfort-oriented care.6
Why do defaults exert these effects? A common explanation
proposes mechanical, social, and psychological factors.1,7 Mechani-
cally, selecting an alternative option involves extra effort (eg, filling out
a form). Socially, defaults may be viewed as prescriptive norms or
implicit recommendations from authority. Psychologically, indi-
viduals who deviate from defaults feel an increased responsibility
for the consequences of that decision. In the face of uncertainty,
risk aversion dissuades this approach.8 To be clear, defaults are not
intended to trick decision makers. They instead leverage the insight
that—for many people in many situations—preferences are not
deeply held but constructed during the process of elicitation.9
There are many methods of influencing choice. These
interventions fall along a spectrum of intrusiveness, with defaults
situated toward the middle.10 At one end of the spectrum are
minimally intrusive measures, such as providing information. A
widely known example is the Choosing Wisely campaign, in which
specialty societies publish lists of overused tests and procedures
that patients and physicians should question.11 At the other end of
the spectrum are maximally intrusive measures, such as restricting
or eliminating choice. In a well-publicized example, a cancer center
assessed two angiogenesis inhibitors used to treat colorectal can-
cer.12 Despite nearly equal efficacy, one drug cost twice as much as
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COMMENTS AND CONTROVERSIES
the other. The hospital therefore declined to carry the more
expensive medication on its formulary. Eliminating choice in this
manner is highly effective at influencing behavior—but also
maximally intrusive to decision makers. Such methods might be
justified when one option is essentially “no value” and when there
is a broad mandate for intervention from patients and physicians.13
In other circumstances, a less heavy-handed approach would be
appealing. If guidelines have not been effective14 and stakeholders
wish to gently influence behavior while preserving choice, defaults
can be considered. Although it is paternalistic to intentionally
design defaults toward a particular outcome, the key feature of this
“soft” or “libertarian” paternalism is that it maintains the option to
choose otherwise with minimal effort.15,16 In the setting of finite
health care resources, we believe that consciously constructing
defaults to promote high-quality, high-value care is an appropriate
and important effort.17-19
Who would set these defaults? This essential question is a
developing area of research and practice. Both health systems and
health care providers may be interested—ideally with involvement
of and feedback from affected decision makers.20 When deter-
mining which option to promote, stakeholders might weigh a
variety of end points, including effectiveness, impact on quality of
life, and cost. The resulting defaults can be designed in several ways,
requiring careful consideration of the clinical situation. A classi-
fication scheme proposed by Goldstein et al21 may prove helpful
when contemplating specific scenarios. Mass defaults are used in
the absence of individualized patient information. One example is
a “benign” default, which selects the single best option for the
majority of patients. Another is the “hidden option,” which dis-
plays only the default option; other choices exist but require
additional searching. The alternatives to mass defaults are person-
alized defaults. For example, a “smart” default is tailored to patient-
and disease-specific characteristics. A more advanced version is the
“adaptive” default, which dynamically updates based on new
information. The electronic medical record is a promising avenue
to achieve these defaults22-24; however, such systems face inherent
challenges (eg, interoperability issues and differences in data
formats or coding vocabularies) for certain types of patient and
disease information.25 Therefore, we suggest that variables used for
personalized defaults should have standardized terminologies and
be captured as structured data elements.26
We believe that defaults could be used across the continuum of
cancer care (Table 1).27 In particular, they may nudge patients and
providers away from low-quality or low-value practices. Three
Journal of Clinical Oncology, Vol 34, No 16 (June 1), 2016: pp 1844-1847
 Comments and Controversies
examples are discussed in more detail in the following paragraphs.
These examples are selected predominantly from the treatment
phase of the continuum, which represents a substantial portion of
cancer costs49 and is frequently the focus of Choosing Wisely
lists.28,31,41
Consider expensive therapeutic drugs that have more cost-
effective alternatives. There is increasing focus on evaluating the
incremental benefits versus costs of these new cancer medications.50
In one example, a health system assessed two drugs for preventing
skeletal-related events from solid tumors. 38 Denosumab was
superior to zolendronic acid in reducing this risk; however,
denosumab failed to affect survival or disease progression, nor did
it offer clinically meaningful benefits for quality-of-life or pain
outcomes.38 Because denosumab was twice the cost of zolendronic
acid, the institution wished to promote the use of zolendronic
acid—yet, it also wanted to maintain the option of denosumab for
less common but appropriate indications. The institution therefore
embarked on a campaign of physician education and dissem-
ination of institutional guidelines; however, only a 65% adherence
rate was achieved. We think that adherence in these situations
could be boosted by a hidden-option default in the electronic order
entry system. For example, searches for either medication would
return only the cost-effective or guideline-concordant medication.
The alternative drug would still be available, but only after additional
database look up. Nonrandomized data from the primary care
setting suggests that this approach increases the prescription of
generic medications.5 The emerging biosimilar drug class may be
particularly well suited to this default and could represent an
attractive opportunity to increase value.51
Another area for improvement is the use of antiemetics during
chemotherapy. Multiple guidelines provide evidence-based
antiemetic regimens tailored to particular chemotherapies,
and patients who receive guideline-concordant medications
experience less nausea and vomiting.52 However, overtreatment
Table 1. Examples of Hypothetical Default Options Across the Cancer Continuum
Cancer Continuum27 Example of Low-Value Care
Screening Cancer screening in patients with limited life
expectancy28-30
Diagnosis Excessive imaging work-up for early-stage cancers31,32
Treatment Guideline-discordant antiemetics during
chemotherapy28,35
Medications with more cost-effective “generic” or
biosimilar alternatives38,39
Conventionally fractionated RT for certain breast
cancers40,41
Survivorship Imaging surveillance that is too frequent43 or too
advanced28,44
End-of-life care Multifraction RT for palliation of uncomplicated bone
metastases45,46
End-of-life care discordant with patient values and
preferences48
Abbreviation: RT, radiotherapy.
*Studies cited in this column provide evidence to support the general concept or feasibility of the hypothetical default.
†Decision makers are both physician (ordering test) and patient (completing test). All other defaults affect physicians as the decision makers.
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during low-emetogenic chemotherapy and undertreatment during
highly emetogenic chemotherapy both are common,33,52,53 landing
antiemetic prescribing on the most recent American Society of
Clinical Oncology Choosing Wisely list.28 Defaults incorporated
into electronic order sets could help address this issue. Chemo-
therapy order sets display a cluster of associated order options—for
example, checkboxes or dropdown lists for standard supportive
medications, antiemetics, and hydration.54 By using smart defaults,
the order sets could pair guideline-concordant antiemetics with
each chemotherapy regimen. In one configuration, the specific
antiemetics would be listed, and their order boxes would be
prechecked. An alternative method would have all chemotherapy
order sets display a single prechecked box labeled “guideline-
concordant antiemetics,” which would trigger the pharmacist to
dispense appropriate medications. Nonrandomized data suggest
that both default approaches may effectively change antiemetic
ordering habits.36,37,55
In the radiotherapy realm, prescriptions specify both the total
dose and the fractionation (ie, number of treatments). A short-
course, or hypofractionated, regimen might be considered the
radiotherapy version of a generic prescription. Hypofractionated
regimens offer equivalent treatment benefit with more convenience
and lower cost for certain breast cancers and bone metastases.40,56
Yet, shorter courses are not widely used,45,57 prompting the
American Society for Radiation Oncology and the American
Academy of Hospice and Palliative Medicine to include this issue in
their Choosing Wisely lists.41,46 In contrast to simple pharmaco-
therapies, fractionation of radiotherapy may be less strongly
influenced by pure defaults in the electronic health record. This is
because the decision about treatment course is often made at the
time of consultation with patients rather than when orders are
entered into the computer. Such a workflow model creates
additional effort (eg, notifying and discussing with the patient) if
the physician wishes to later change from a nondefault to a default
Hypothetical Default* Default Type21
Automated, opt-out appointments for screening tests Adaptive
that are initiated and continue according to guidelines
but that stop once life expectancy is limited4†
Diagnosis- and stage-specific order sets defaulted to Smart
show only guideline-concordant tests33,34
Chemotherapy-specific order sets that default to Smart
guideline-concordant antiemetics36,37
Order entry system shows only “generic” option when Hidden option
either medication is searched; alternative is available
but requires additional database look up5
Patient-specific care pathways defaulted to Smart
hypofractionated breast RT for eligible patients;
deviation from default prompts peer review42
Automated, opt-out appointments for surveillance Adaptive
imaging starting at end of treatment; overridden if
abnormal results or clinical concerns arise4†
Care pathways defaulted to single-fraction RT for bone Smart
metastases; deviation from default prompts peer
review47
Default options in advance care directives6 Benign
© 2016 by American Society of Clinical Oncology 1845
 Ojerholm, Halpern, and Bekelman
choice. More influence is expected if the default can be incorporated
at the moment of decision making, ideally coincident with the
patient encounter. Nonetheless, some health systems require
radiation oncologists to document the consistency of their treat-
ment decisions with institutional guidelines or care pathways. In
this context, hypofractionated regimens could be set as the
guideline-concordant, default option for the treatment of certain
breast cancers and bone metastases. This would support the in-
stitutional guidelines and may create carryover effects to future
consultations. Personalized feedback and accountability could be
achieved through peer review of cases that deviate from the
default.20 Nonrandomized data suggest the viability of this
approach. 42,47
Although defaults hold promise, they also carry caveats and
concerns. Seemingly logical defaults may not yield meaningful
improvements when formally evaluated, and they may even have
unintended consequences. In one study, a hospital admissions
order set successfully increased the rate of venous thromboemb-
olism prophylaxis—but mostly in patients with contraindications
who could have been harmed.58 This underscores the importance
of default design (eg, smart v benign) and the need for rigorous
testing instead of empiric implementation.59 Furthermore, complexities
of medical decision making can limit our ability to extrapolate results
from one clinical context to another.60 For example, default opt-out
appointments increased influenza vaccinations4 but did not improve
colonoscopy screening,61 demonstrating the need for oncology-
specific evidence. Additional questions may be raised for defaults
that use a generic format, such as an order box labeled “guideline-
concordant antiemetics.” This formatting requires a pharmacist to
operationalize the general intent of a physician. Although
previously implemented and reported in the literature,36 such
an approach could be viewed as a meaningful shift of professional
autonomy. There are also a number of ethical considerations that
govern the design and use of defaults, as discussed in detail
elsewhere.62-64 These include the use of defaults rather than
inflexible clinical policies when there is a generally preferable
action but a need to allow patients or physicians to opt out in
unique circumstances; the importance of ensuring that decision
makers are aware that there are choices to be made, so they may opt
out when sufficiently motivated to do so; and the requirement that
stakeholders who set defaults be accountable for their effects.62-64 A
final concern is that defaults could hinder physician knowledge.
For example, if order sets automatically present guideline-concordant
medications, will physicians lose the educational value of seeking out
and integrating that information on their own? Fortunately, studies
of inpatient protocol implementation suggest that this theoretical
concern is not borne out in real practice.65,66
What role will defaults ultimately play in cancer care? There
are plenty of opportunities for future research (Table 1). Some
concepts, such as adaptive defaults for screening and imaging
surveillance, might only be feasible after advances occur in elec-
tronic health systems.67 We suggest that the three examples dis-
cussed in the preceding paragraphs are prime candidates for
additional study. Investigations can test which defaults successfully
change behavior, quantify the magnitude of the effect, and determine
the optimal implementation method. Strong experimental design
is essential. Common approaches include pre-post studies or
randomized controlled trials. Pre-post studies measure an outcome
1846 © 2016 by American Society of Clinical Oncology
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Copyright © 2022 American Society of Clinical Oncology. All rights reserved.
both before and after an intervention; any change is assumed to
represent the impact of the intervention. This design is regarded as
weak because observed changes may be due to the intervention or
to other measured or unmeasured factors that also change over
time. For interventions targeted at health care providers, randomized
evaluations may be designed as cluster-randomized trials, which
involve random assignment of providers or groups of providers to
interventions or usual care.68,69 Cluster-randomized trials have
important limitations and may be infeasible; alternative exper-
imental designs may be more practical but also have short-
comings. Careful consideration of experimental design is crucial to
evaluate the effectiveness of default options. Ultimately, well-
designed research conducted in the health care delivery setting
will allow rapid adoption and full-scale implementation contingent
on favorable results. If successful, these studies could open new
avenues to improve quality and value in oncology—by default.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Disclosures provided by the authors are available with this article at
www.jco.org.
AUTHOR CONTRIBUTIONS
Manuscript writing: All authors
Final approval of manuscript: All authors
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© 2016 by American Society of Clinical Oncology 1847
 Ojerholm, Halpern, and Bekelman

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Default Options: Opportunities to Improve Quality and Value in Oncology
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are
self-held unless noted. I 5 Immediate Family Member, Inst 5 My Institution. Relationships may not relate to the subject matter of this manuscript. For more
information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc.
Eric Ojerholm Justin E. Bekelman
No relationship to disclose No relationship to disclose
Scott D. Halpern
Other Relationship: Paid consultant to the American Board of Internal
Medicine Foundation’s Choosing Wisely campaign

© 2016 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY

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Acknowledgment

Supported in part by a Greenwall Foundation Faculty Scholar Award in Bioethics (to S.D.H.), by Grant No. K07-CA163616 from the
National Cancer Institute (to J.E.B.), and by the Young Friends of the Abramson Cancer Center Fund (to J.E.B.). We thank Gregory Winter
and Tomas Patrich of the University of Pennsylvania, who were paid for their contributions as part of a summer undergraduate research
fellowship in the Department of Radiation Oncology, for thoughtful discussion and research assistance. We also thank Peter Gabriel, MD,
MSE, Chief Oncology Informatics Officer of the Abramson Cancer Center at the University of Pennsylvania, who was not compensated for
his effort, for helpful assistance during revisions.

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