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Bredbeck BC, Mott NM, Wang T, Sinco BR, Hughes TM, Nathan H, Dossett LA. ASO Visual Abstract: Facility-Level Variation of Low-Value Breast Cancer Treatments in Older Women with Early-Stage Breast Cancer: Analysis of a Statewide Claims Registry. Ann Surg Oncol 2022. [DOI: 10.1245/s10434-022-11743-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Bredbeck BC, Mott NM, Wang T, Sinco BR, Hughes TM, Nathan H, Dossett LA. Facility-Level Variation of Low-Value Breast Cancer Treatments in Older Women with Early-Stage Breast Cancer: Analysis of a Statewide Claims Registry. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11631-z. [PMID: 35380309 DOI: 10.1245/s10434-022-11631-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Since 2004, national guidelines have supported the omission of sentinel lymph node biopsy (SLNB) and radiotherapy for women ≥ 70 years of age with early-stage, hormone receptor-positive (HR+) breast cancer, but many women continue to receive at least one of these services. Provider- and patient-level factors may contribute to persistent utilization, but the role of facility-level factors is unknown. We aimed to determine facility-level variation of SLNB and adjuvant radiotherapy utilization in older women with early-stage, HR+ breast cancer undergoing breast-conserving surgery (BCS). Additionally, we aimed to explore factors associated with SLNB and radiotherapy utilization and the intra-facility correlation in their utilization. METHODS We conducted a retrospective cohort study using a statewide registry of claims data. We included women ≥70 years of age diagnosed with breast cancer who underwent BCS from 2012 to 2019 at 80 hospitals in the Michigan Value Collaborative. The main outcome was inter-facility rates and variation of SLNB and radiotherapy, as well as intra-facility correlation in their utilization. RESULTS The cohort included 7253 women (median age 77 years). Only 20% (n = 1440) underwent BCS alone, whereas 71% (n = 5122) underwent SLNB and 52% (n = 3793) received radiotherapy. Inter-facility rates of SLNB ranged from 35 to 82% (median 70%), and radiotherapy ranged from 19 to 72% (median 49%). SLNB and radiotherapy were positively correlated (r = 0.27, p = 0.016). CONCLUSIONS SLNB and radiotherapy rates remain high with significant variation in utilization at the facility level. High utilizers of SLNB are likely to be high utilizers of radiotherapy, suggesting the opportunity for strategic targeting of these facilities and their clinicians.
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Mott NM, Dossett LA. Opportunities and Challenges of Defining "Value" in Oncology Care. Ann Surg Oncol 2022; 29:6518-6519. [PMID: 35316434 DOI: 10.1245/s10434-022-11548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/21/2022] [Indexed: 11/18/2022]
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Bredbeck BC, Delaney LD, Kathawate VG, Harter CA, Wilkowski J, Chugh R, Cuneo KC, Dossett LA, Sabel MS, Angeles CV. Factors associated with disease-free and abdominal recurrence-free survival in abdominopelvic and retroperitoneal sarcomas. J Surg Oncol 2022; 125:1292-1300. [PMID: 35239187 PMCID: PMC9313796 DOI: 10.1002/jso.26828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 11/07/2022]
Abstract
Background and Objectives Retroperitoneal and abdominopelvic sarcomas are rare heterogeneous malignancies. The only therapy proven to improve disease‐free survival (DFS) is R0/R1 surgical resection. We sought to analyze whether additional factors such as radiation and systemic therapy were associated with DFS and abdominal recurrence‐free survival (RFS). Methods Retrospective review of adults (≥18) with resectable abdominopelvic and retroperitoneal sarcomas who underwent intent‐to‐cure surgery at a high‐volume tertiary referral center between 1998 and 2015. The main outcome measures were DFS and abdominal RFS. Results Overall, 159 patients met the criteria for inclusion. Median follow‐up was 4.8 years (range 0.1–18.9 years). The most common histology was liposarcoma (49%). Systemic therapy was administered to 48% of patients and was not associated with improved outcomes. The neoadjuvant radiotherapy group (11%) had improved adjusted DFS (5.46 years, 95% CI [3.68, 7.24] vs. 3.1 years, 95% CI [2.48, 3.73]) and abdominal RFS (6.14 years, 95% CI [4.38, 7.89] vs. 3.22 years, 95% CI [2.61, 3.84]). The adjuvant radiotherapy group (19%) had no improvement. Conclusions In a cohort of patients undergoing resection for retroperitoneal or abdominopelvic sarcoma, neoadjuvant radiation improved DFS and abdominal RFS. A follow‐up of over three years was needed to appreciate a difference in outcomes.
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Ellsworth BL, Metz AK, Mott NM, Kazemi R, Stover M, Hughes T, Dossett LA. ASO Visual Abstract: Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care. Ann Surg Oncol 2022. [PMID: 35235088 DOI: 10.1245/s10434-022-11394-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Coleman DM, Perrone EE, Dombrowski J, Dossett LA, Sears ED, Sandhu G, Telem DA, Waljee JF, Newman EA. Overcoming COVID-19: Strategies to Mitigate the Perpetuated Gender Achievement Gap. Ann Surg 2022; 275:435-437. [PMID: 34387196 PMCID: PMC8820744 DOI: 10.1097/sla.0000000000005149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sex inequity in academic achievement was well documented before the COVID-19 pandemic, and evolving data suggest that women in academic surgery are disproportionately disadvantaged by the pandemic. This perspective piece reviews currently accepted solutions to the sex achievement gap, with their associated shortcomings. We also propose innovative strategies to overcoming barriers to sex equity in academic medicine that broadly fall into three categories: strategies to mitigate inequitable caregiving responsibilities, strategies to reduce cognitive load, and strategies to value uncompensated, impactful work. These approaches address inequities at the system-level, as opposed to the individual-level, lifting the burden of changing the system from women.
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Chen MM, Hughes TM, Dossett LA, Pitt SC. Peace of Mind: A Role in Unnecessary Care? J Clin Oncol 2022; 40:433-437. [PMID: 34882501 PMCID: PMC8824400 DOI: 10.1200/jco.21.01895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/05/2021] [Accepted: 11/12/2021] [Indexed: 12/20/2022] Open
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Ellsworth BL, Metz AK, Mott NM, Kazemi R, Stover M, Hughes T, Dossett LA. Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care. Ann Surg Oncol 2022; 29:3750-3762. [DOI: 10.1245/s10434-021-11303-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/18/2021] [Indexed: 12/28/2022]
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Bredbeck BC, Baskin AS, Wang T, Sinco BR, Berlin NL, Shubeck SP, Mott NM, Greenup RA, Nathan H, Hughes TM, Dossett LA. Incremental Spending Associated with Low-Value Treatments in Older Women with Breast Cancer. Ann Surg Oncol 2022; 29:1051-1059. [PMID: 34554342 DOI: 10.1245/s10434-021-10807-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND In most women ≥ 70 years old with hormone-receptor-positive breast cancer, axillary staging and adjuvant radiotherapy provide no survival advantage over surgery and hormone therapy alone. Despite recommendations for their omission, sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy rates remain high. While treatment side effects are well documented, less is known about the incremental spending associated with SLNB and adjuvant radiotherapy. METHODS Using a statewide multipayer claims registry, we examined spending associated with breast cancer treatment in a retrospective cohort of women ≥ 70 years old undergoing surgery. RESULTS 9074 women ≥70 years old underwent breast cancer resection between 2012 and 2019, with 78% (n = 7122) receiving SLNB and/or adjuvant radiotherapy within 90 days of surgery. Women undergoing SLNB were more likely to receive radiation (51% vs. 28%; p < 0.001 and OR = 2.68). Average 90-day spending varied substantially based upon treatment received, ranging from US$10,367 (breast-conserving surgery alone) to US$27,370 (mastectomy with SLNB and adjuvant radiotherapy). The relative increases in 90-day treatment spending in the breast-conserving surgery cohort was 65% for SLNB, 82% for adjuvant radiotherapy, and 120% for both treatments. CONCLUSIONS SLNB and adjuvant radiotherapy have significant spending implications in older women with breast cancer, even though they are unlikely to improve survival.
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Dossett LA, Mott NM, Bredbeck BC, Wang T, Jobin CTC, Hughes TM, Hawley ST, Zikmund-Fisher BJ. Using Tailored Messages to Target Overuse of Low-Value Breast Cancer Care in Older Women. J Surg Res 2022; 270:503-512. [PMID: 34801801 PMCID: PMC8734932 DOI: 10.1016/j.jss.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/19/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND National recommendations allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70 y/o with early-stage, hormone-receptor positive invasive breast cancer, but these therapies remain common. Previous work demonstrates an individual's maximizing-minimizing trait-an inherent preference for more or less medical care-may influence the preference for low-value care. MATERIALS AND METHODS We recruited an equal number of women ≥ 70 yrs who were maximizers, minimizers, or neutral based on a validated measure between September 2020 and November 2020. Participants were presented a hypothetical breast cancer diagnosis before randomization to one of three follow-up messages: maximizer-tailored, minimizer-tailored, or neutral. Tailored messaging aimed to redirect maximizers and minimizers toward declining SLNB and radiotherapy. The main outcome measure was predicted probability of choosing SLNB or radiotherapy. RESULTS The final analytical sample (n = 1600) was 515 maximizers (32%), 535 neutral (33%) and 550 (34%) minimizers. Higher maximizing tendency positively correlated with electing both SLNB and radiotherapy on logistic regression (P < 0.01). Any tailoring (maximizer- or minimizer-tailored) reduced preference for SLNB in maximizing and neutral women but had no effect in minimizing women. Tailoring had no impact on radiotherapy decision, except for an increased probability of minimizers electing radiotherapy when presented with maximizer-tailored messaging. CONCLUSIONS Maximizing-minimizing tendencies are associated with treatment preferences among women facing a hypothetical breast cancer diagnosis. Targeted messaging may facilitate avoidance of low-value breast cancer care, particularly for SLNB.
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Hughes TM, Ellsworth B, Berlin NL, Sinco B, Bredbeck B, Baskin A, Wang T, Nathan H, Dossett LA. Statewide Episode Spending Variation of Mastectomy for Breast Cancer. J Am Coll Surg 2022; 234:14-23. [PMID: 35213456 DOI: 10.1097/xcs.0000000000000005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Centralizing complex cancer operations, such as pancreatectomy and esophagectomy, has been shown to increase value, largely due to reduction in complications. For high-volume operations with low complication rates, it is unknown to what degree value varies between facilities, or by what mechanism value may be improved. To identify possible opportunities for value enhancement for such operations, we sought to describe variations in episode spending for mastectomy with a secondary aim of identifying patient- and facility-level determinants of variation. STUDY DESIGN Using the Michigan Value Collaborative risk-adjusted, price-standardized claims data, we evaluated mean spending for patients undergoing mastectomy at 74 facilities (n = 7,342 patients) across the state of Michigan. Primary outcomes were 30- and 90-day episode spending. Using linear mixed models, facility- and patient-level factors were explored for association with spending variability. RESULTS Among 7,342 women treated across 74 facilities, mean 30-day spending by facility ranged from $11,129 to $20,830 (median $14,935). Ninety-day spending ranged from $17,303 to $31,060 (median $23,744). Patient-level factors associated with greater spending included simultaneous breast reconstruction, bilateral surgery, length of stay, and readmission. Among women not undergoing reconstruction, variation persisted, and length of stay, bilateral surgery, and readmission were all associated with increased spending. CONCLUSION Michigan hospitals have significant variation in spending for mastectomy. Reducing length of stay through wider adoption of same-day discharge for mastectomy and reducing the frequency of bilateral surgery may represent opportunities to increase value, without compromising patient safety or oncologic outcomes.
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Duffy B, Miller J, Vitous CA, Dossett LA. Intersystem Medical Error Discovery: A Document Analysis of Ethical Guidelines. J Patient Saf 2021; 17:e1765-e1773. [PMID: 32168281 PMCID: PMC7483979 DOI: 10.1097/pts.0000000000000625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patient safety programs aim to improve transparency regarding medical errors, and there is broad consensus on how providers should communicate about their own errors. How providers should respond to other providers' errors is less clear, especially when they occur outside the provider's facility or system (intersystem medical error discovery [IMED]). To understand what guidance is available to healthcare professionals in this scenario, we conducted a document analysis of ethical guidelines. METHODS We searched for ethics codes primarily using databases and lists of professional associations. We used thematic analysis to examine documents in relation to our research questions: is there guidance on (a) what a provider should do after discovering another provider's error that occurred in a different health system, (b) interacting with other providers, or (c) other subjects relevant to IMED? RESULTS Our search identified 150 documents from 120 organizations. These documents contained ambiguous terminology and guidance limiting practical application to IMED scenarios, with most guidance potentially applicable to IMED rendered irrelevant to most IMED scenarios by its restriction to incompetence. In addition, guidelines often sent conflicting signals about prioritizing honesty with and autonomy of patients versus not criticizing the care provided by a fellow practitioner. CONCLUSIONS Ethics codes provide little guidance on communication regarding IMED scenarios, and in some cases, the guidance is internally conflicting. National professional and patient safety organizations should work to provide a framework for providers and facilities to communicate regarding these ethically and professionally challenging scenarios.
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Chen MM, Mott NM, Miller J, Kazemi R, Stover M, Graboyes EM, Divi V, Malloy KM, Wallner LP, Pitt SC, Dossett LA. Clinician Attitudes and Beliefs About Deintensifying Head and Neck Cancer Surveillance. JAMA Otolaryngol Head Neck Surg 2021; 148:43-51. [PMID: 34734995 DOI: 10.1001/jamaoto.2021.2824] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Surveillance imaging and visits are costly and have not been shown to improve oncologic outcomes for patients with head and neck cancer (HNC). However, the benefit of surveillance visits may extend beyond recurrence detection. To better understand surveillance and potentially develop protocols to tailor current surveillance paradigms, it is important to elicit the perspectives of the clinicians who care for patients with HNC. Objective To characterize current surveillance practices and explore clinician attitudes and beliefs on deintensifying surveillance for patients with HNC. Design, Setting, and Participants This qualitative study was performed from January to March 2021. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from March to April 2021. Otolaryngologists and radiation oncologists were recruited using purposive and snowball sampling strategies. Main Outcomes and Measures The main outcomes were current practice, attitudes, and beliefs about deintensifying surveillance and survivorship as well as patients' values and perspectives collected from interviews of participating physicians. Results Twenty-one physicians (17 [81%] men) were interviewed, including 13 otolaryngologists and 8 radiation oncologists with a median of 8 years (IQR, 5-20 years) in practice. Twelve participants (57%) stated their practice comprised more than 75% of patients with HNC. Participants expressed that there was substantial variation in the interpretation of the surveillance guidelines. Participants were open to the potential for deintensification of surveillance or incorporating symptom-based surveillance protocols but had concerns that deintensification may increase patient anxiety and shift some of the burden of recurrence monitoring to patients. Patient and physician peace of mind, the importance of maintaining the patient-physician relationship, and the need for adequate survivorship and management of treatment-associated toxic effects were reported to be important barriers to deintensifying surveillance. Conclusions and Relevance In this qualitative study, clinicians revealed a willingness to consider altering cancer surveillance but expressed a need to maintain patient and clinician peace of mind, maintain the patient-clinician relationship, and ensure adequate monitoring of treatment-associated toxic effects and other survivorship concerns. These findings may be useful in future research on the management of posttreatment surveillance.
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Hughes TM, Berlin NL, Ellsworth B, Sinco BR, Wang T, Bredbeck B, Dossett LA. Variations in Episode Spending for Breast Cancer Patients Undergoing Mastectomy: Results From a Statewide Value Collaborative. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Baskin AS, Wang T, Miller J, Jagsi R, Kerr EA, Dossett LA. A Health Systems Ethical Framework for De-implementation in Health Care. J Surg Res 2021; 267:151-158. [PMID: 34153558 PMCID: PMC8678146 DOI: 10.1016/j.jss.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/19/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Unnecessary health care not only drive up costs, but also contribute to avoidable patient harms, underscoring an ethical obligation to eliminate practices which are harmful, lack evidence, and prevent spending on more beneficial services. To date, de-implementation ethics discussions have been limited and focused on clinical ethics principles. An analysis of de-implementation ethics in the broader context of the health care system is lacking. METHODS To better understand the ethical considerations of de-implementation, recognizing it as a health care systems issue, we applied Krubiner and Hyder's bioethical framework for health systems activity. We examine ethics principles relevant to de-implementation, which either call for or facilitate the reduction of low value surgery. RESULTS AND DISCUSSION From 11 health systems principles proposed by Krubiner and Hyder, we identified the 5 principles most pertinent to the topic of de-implementation: evidence and effectiveness, transparency and public engagement, efficiency, responsiveness, and collaboration. An analysis of de-implementation through the lens of these principles not only supports de-implementation but proves an obligation at the health system level to eliminate low value care. Recognizing the challenge of defining "value," the proposed framework may increase the legitimacy and objectivity of de-implementation. CONCLUSIONS While there is no single ideal ethical framework from which to approach de-implementation, a health systems framework allows for consideration of the systems-level factors impacting de-implementation. Framing de-implementation as a health systems issue with systems-wide ethical implications empowers providers to think about new ways to approach potential roadblocks to reducing low-value care.
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Dossett LA, Dimick JB. Surgical Volumes and Readiness-Challenges of Declining Cases for the Military Surgeon. JAMA Surg 2021; 157:50-51. [PMID: 34705040 DOI: 10.1001/jamasurg.2021.5337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Bredbeck BC, Dossett LA. ASO Author Reflections: Adding up the Costs of Low-Value Breast Cancer Care. Ann Surg Oncol 2021; 29:1060. [PMID: 34586521 DOI: 10.1245/s10434-021-10863-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 11/18/2022]
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Dossett LA, Kaji AH, Cochran A. SRQR and COREQ Reporting Guidelines for Qualitative Studies. JAMA Surg 2021; 156:875-876. [PMID: 33825809 DOI: 10.1001/jamasurg.2021.0525] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Hughes TM, Dossett LA. Financial Toxicity: Exploring the Role of Treatment Choice. J Am Coll Surg 2021; 233:456-458. [PMID: 34446218 DOI: 10.1016/j.jamcollsurg.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
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Berlin NL, Yost ML, Cheng B, Henderson J, Kerr E, Nathan H, Dossett LA. Patterns and Determinants of Low-Value Preoperative Testing in Michigan. JAMA Intern Med 2021; 181:1115-1118. [PMID: 33999103 PMCID: PMC8129898 DOI: 10.1001/jamainternmed.2021.1653] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 12/24/2022]
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Coleman DM, Dossett LA, Dimick JB. Building high performing teams: Opportunities and challenges of inclusive recruitment practices. J Vasc Surg 2021; 74:86S-92S. [PMID: 34303464 DOI: 10.1016/j.jvs.2021.03.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/23/2021] [Indexed: 11/17/2022]
Abstract
Healthcare is most effectively delivered by high-performance teams, which require, not simply talent, but also diversity in their members, supported by a culture of equity that is open, supportive, and inclusive. Cognitive diversity offers a performance advantage, improving collective understanding and optimizing high-complexity problem solving. Diverse teams have been shown to outperform homogenous team, and this diversity, supplemented with equity and inclusion, yields a superior creative culture. High-performance teams rest on a foundation of standardized and inclusive recruitment practices. Standard recruitment procedures have been insufficient in broadening representation owing to the long-standing inequities and exclusion in medicine. As such, we have highlighted the opportunities for inclusive recruitment practices.
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Baskin AS, Dossett LA, Harris CA. Cultural Complications Curriculum: Applicability to Surgical Oncology Programs and Practices. Ann Surg Oncol 2021; 28:4088-4092. [PMID: 34106386 PMCID: PMC8188763 DOI: 10.1245/s10434-021-10274-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/17/2021] [Indexed: 11/18/2022]
Abstract
Background Recognizing the need to raise awareness of core diversity, equity, and inclusion (DEI) issues in the healthcare system, our previously developed Cultural Complications Curriculum aims to support institutions in reducing cultural error. As we continue program deployment, we discuss the opportunity to apply the Cultural Complications Curriculum to multidisciplinary audiences, such as in cancer programs. Methods We discuss applicability of the Cultural Complications Curriculum to cancer programs and practices, including how to tailor case discussions to oncology audiences. By emphasizing the unique characteristics of the multidisciplinary care environment and anticipating potential barriers to curriculum implementation, we demonstrate how the Cultural Complications Curriculum may support culture improvement across broad audiences. Results The successful application of the Cultural Complication Curriculum to multidisciplinary care programs will depend on appreciating differences in background knowledge, tailoring discussions to audience needs, and adapting material by incorporating new data and addressing emerging DEI issues. Multidisciplinary environments may require innovative approaches to education including virtual platforms, increased collaboration across centers and systems, and support from professional societies. In integrated care environments, like oncology, effective DEI discussions call for the engagement of a variety of medical specialties and departments. Conclusions To meet the needs of an increasingly diverse patient population and workforce, our approach to DEI education must embrace the interdependent nature of care delivery. In oncology and other multidisciplinary care environments, application of the Cultural Complications Curriculum may be the first step to combating cultural error by engaging a broader demographic within our healthcare system.
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Clarke CN, Cortina CS, Fayanju OM, Dossett LA, Johnston FM, Wong SL. Breast Cancer Risk and Screening in Transgender Persons: A Call for Inclusive Care. Ann Surg Oncol 2021; 29:2176-2180. [PMID: 34097159 DOI: 10.1245/s10434-021-10217-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/16/2021] [Indexed: 01/10/2023]
Abstract
The Society of Surgical Oncology is committed to reducing health disparities adversely affecting sexual and gender minorities. Transgender persons represent a socially disadvantaged group who frequently experience discrimination and receive disparate care, resulting in suboptimal cancer outcomes. The rate of breast cancer development in transgender individuals differs from rates observed in their cisgender counterparts, however there is little evidence to quantify these differences and guide evidence-based screening and prevention. There is no consensus for breast cancer screening guidelines in transgender patients. In this review, we discuss barriers to equitable breast cancer care, risk factors for breast cancer development, and existing data to support breast cancer screening in transgender men and women.
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Abstract
This study uses data from the 2010-2018 National Health Interview Survey to characterize trends in human papillomavirus (HPV) vaccination rates, ages at vaccination, and numbers of doses received among young adults in the US between 2010 and 2018.
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Broman KK, Hughes TM, Dossett LA, Sun J, Carr MJ, Kirichenko DA, Sharma A, Bartlett EK, Nijhuis AA, Thompson JF, Hieken TJ, Kottschade L, Downs J, Gyorki DE, Stahlie E, van Akkooi A, Ollila DW, Frank J, Song Y, Karakousis G, Moncrieff M, Nobes J, Vetto J, Han D, Farma J, Deneve JL, Fleming MD, Perez M, Baecher K, Lowe M, Bagge RO, Mattsson J, Lee AY, Berman RS, Chai H, Kroon HM, Teras RM, Teras J, Farrow NE, Beasley GM, Hui JY, Been L, Kruijff S, Boulware D, Sarnaik AA, Sondak VK, Zager JS. Surveillance of Sentinel Node-Positive Melanoma Patients with Reasons for Exclusion from MSLT-II: Multi-Institutional Propensity Score Matched Analysis. J Am Coll Surg 2021; 232:424-431. [PMID: 33316427 PMCID: PMC8764869 DOI: 10.1016/j.jamcollsurg.2020.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND In sentinel lymph node (SLN)-positive melanoma, two randomized trials demonstrated equivalent melanoma-specific survival with nodal surveillance vs completion lymph node dissection (CLND). Patients with microsatellites, extranodal extension (ENE) in the SLN, or >3 positive SLNs constitute a high-risk group largely excluded from the randomized trials, for whom appropriate management remains unknown. STUDY DESIGN SLN-positive patients with any of the three high-risk features were identified from an international cohort. CLND patients were matched 1:1 with surveillance patients using propensity scores. Risk of any-site recurrence, SLN-basin-only recurrence, and melanoma-specific mortality were compared. RESULTS Among 1,154 SLN-positive patients, 166 had ENE, microsatellites, and/or >3 positive SLN. At 18.5 months median follow-up, 49% had recurrence (vs 26% in patients without high-risk features, p < 0.01). Among high-risk patients, 52 (31%) underwent CLND and 114 (69%) received surveillance. Fifty-one CLND patients were matched to 51 surveillance patients. The matched cohort was balanced on tumor, nodal, and adjuvant treatment factors. There were no significant differences in any-site recurrence (CLND 49%, surveillance 45%, p = 0.99), SLN-basin-only recurrence (CLND 6%, surveillance 14%, p = 0.20), or melanoma-specific mortality (CLND 14%, surveillance 12%, p = 0.86). CONCLUSIONS SLN-positive patients with microsatellites, ENE, or >3 positive SLN constitute a high-risk group with a 2-fold greater recurrence risk. For those managed with nodal surveillance, SLN-basin recurrences were more frequent, but all-site recurrence and melanoma-specific mortality were comparable to patients treated with CLND. Most recurrences were outside the SLN-basin, supporting use of nodal surveillance for SLN-positive patients with microsatellites, ENE, and/or >3 positive SLN.
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