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Pesavento CM, Kazemi RJ, Kappelman A, Thompson JL, Jobin C, Wang T, Dossett LA. Pilot testing a patient decision aid as a strategy to reduce overtreatment for older women with early-stage breast cancer. Am J Surg 2024; 235:115774. [PMID: 38834420 DOI: 10.1016/j.amjsurg.2024.115774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/23/2024] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Despite national guidelines recommending omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy (RT) in older women with early-stage, hormone receptor-positive (HR+) breast cancer, these practices persist. This pilot study assesses whether a decision aid can target patient-level determinants of low-value treatments. METHODS We adapted and pilot-tested a decision aid in women ≥70 years old with early-stage HR + breast cancer. Primary outcomes included acceptability and appropriateness of the decision aid. Secondary outcomes included treatment choice and satisfaction with decision. RESULTS Twenty-three patients enrolled in the trial. 19 completed survey one; 16 completed survey two. Primary outcomes demonstrated that 84% of patients agreed or strongly agreed the aid was acceptable and appropriate. Secondary outcomes demonstrated that 19% of patients underwent SLNB (below pre-intervention baseline), and 85% received adjuvant RT (change not statistically significant). CONCLUSIONS We demonstrate that a decision aid may effectively target patient-level factors contributing to overuse of low-value therapies.
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Affiliation(s)
- Cecilia M Pesavento
- University of Michigan Medical School, Ann Arbor, MI, USA; Vanderbilt University Medical Center, Department of Surgery, Nashville, TN, USA.
| | - Ruby J Kazemi
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Abigail Kappelman
- University of Michigan Medical School, Ann Arbor, MI, USA; University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
| | - Jessica L Thompson
- Corewell Health West, Department of Cancer Health, Grand Rapids, MI, USA
| | | | - Ton Wang
- Duke University School of Medicine, Department of Surgery, Durham, NC, USA
| | - Lesly A Dossett
- University of Michigan, Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA; University of Michigan, Department of Surgery, Ann Arbor, MI, USA
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Mensah GA, Fuster V, Roth GA. A Heart-Healthy and Stroke-Free World: Using Data to Inform Global Action. J Am Coll Cardiol 2023; 82:2343-2349. [PMID: 38092508 DOI: 10.1016/j.jacc.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | - Valentin Fuster
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Gregory A Roth
- Department of Health Metrics Sciences, Institute for Health Metrics and Evaluation, School of Medicine, University of Washington, Seattle, Washington, USA; Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
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Conte de Oliveira MD, Fernandes HDS, Vasconcelos AL, Russo FADP, Malheiro DT, Colombo G, Pelegrini P, Berwanger O, Teich V, Marra A, Menezes FGD, Cendoroglo Neto M, Klajner S. Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies. BMJ Open Qual 2023; 12:e002178. [PMID: 37963671 PMCID: PMC10649569 DOI: 10.1136/bmjoq-2022-002178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 10/01/2023] [Indexed: 11/16/2023] Open
Abstract
Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vanessa Teich
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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4
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Sastry RA, Chen JS, Shao B, Weil RJ, Chang KE, Maynard K, Syed SH, Zadnik Sullivan PL, Camara JQ, Niu T, Sampath P, Telfeian AE, Oyelese AA, Fridley JS, Gokaslan ZL. Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019. JAMA Netw Open 2023; 6:e2326357. [PMID: 37523184 PMCID: PMC10391306 DOI: 10.1001/jamanetworkopen.2023.26357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
Importance Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population. Objective To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019. Design, Setting, and Participants This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023. Main Outcome and Measure The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone. Results Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001). Conclusions and Relevance In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Jia-Shu Chen
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Belinda Shao
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Robert J Weil
- Department of Neurosurgery, Brain and Spine, Southcoast Health, Dartmouth, Massachusetts
| | - Ki-Eun Chang
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Ken Maynard
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Sohail H Syed
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Patricia L Zadnik Sullivan
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Joaquin Q Camara
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Tianyi Niu
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Prakash Sampath
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Albert E Telfeian
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Jared S Fridley
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
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Sharma D, Agarwal P, Agrawal V, Bajaj J, Yadav SK. Low Value Surgical Care: Are We Choosing Wisely? Indian J Surg 2023. [DOI: 10.1007/s12262-023-03739-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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Metz AK, Berlin NL, Yost ML, Cheng B, Kerr E, Nathan H, Cuttitta A, Henderson J, Dossett LA. Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse. J Surg Res 2023; 283:93-101. [PMID: 36399802 DOI: 10.1016/j.jss.2022.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/21/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.
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Affiliation(s)
- Allan K Metz
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Monica L Yost
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Bonnie Cheng
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Eve Kerr
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Hari Nathan
- National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan; Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Anthony Cuttitta
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - James Henderson
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Ellsworth BL, Settecerri DJ, Mott NM, Vastardis A, Hider AM, Thompson J, Dossett LA, Hughes TM. Surgeon Perspectives on Determinants of Same-Day Mastectomy: A Roadmap for Implementing Change. Ann Surg Oncol 2023; 30:1712-1720. [PMID: 36536198 PMCID: PMC9762864 DOI: 10.1245/s10434-022-12934-x] [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] [Received: 08/29/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Same-day discharge after mastectomy without immediate reconstruction (MwoR) has been shown to be safe, with improved patient satisfaction when compared with patients discharged 1 or more days after surgery. Nevertheless, only 16% of patients undergoing MwoR in Michigan are discharged on the day of surgery, with significant variation between facilities (3-88%). Our objective was to explore determinants of same-day discharge and offer strategies for broader implementation of this practice. METHODS We conducted semi-structured interviews with surgeons performing MwoR across the state of Michigan. Recruitment utilized purposeful and snowball sampling methods. The Tailored Implementation in Chronic Disease (TICD) framework was used to inform the creation of the interview guide. Interviews were transcribed and then analyzed using directed content analysis guided by the TICD framework. Salient determinants were organized into patient, provider, and system-level factors. RESULTS Participants (n = 26) included general surgeons, breast surgeons, and surgical oncologists. Most surgeons (n = 18, 69%) reported that they discharged fewer than 60% of patients the same day after MwoR. The most common barriers included patient knowledge at the patient level; awareness of evidence, surgeon dogma, and peer influence at the provider level; and team processes and operating room logistics at the system level. CONCLUSION We identified surgeon-defined determinants of same-day discharge after MwoR. For the identified barriers, potential implementation strategies could include incorporation of preoperative drain teachings for patients, utilizing consensus statements and opinion leaders to disseminate evidence supporting same-day mastectomies, and conducting workshops with relevant stakeholders to establish consistent facility practice patterns among surgical teams.
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Affiliation(s)
| | - Daniel J Settecerri
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Nicole M Mott
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Andrew Vastardis
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Ahmad M Hider
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jessica Thompson
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lesly A Dossett
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Tasha M Hughes
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA.
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Varsanik MA, Shubeck SP. De-Escalating Breast Cancer Therapy. Surg Clin North Am 2023; 103:83-92. [DOI: 10.1016/j.suc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ho VT, Aikens RC, Tso G, Heidenreich PA, Sharp C, Asch SM, Chen JH, Shah NK. Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial. J Am Med Inform Assoc 2022; 29:1941-1948. [PMID: 36018731 PMCID: PMC10161518 DOI: 10.1093/jamia/ocac139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/13/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing. MATERIALS AND METHODS We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors. RESULTS Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]). DISCUSSION Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse. CONCLUSION Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines. TRIAL REGISTRATION NCT02709772.
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Affiliation(s)
- Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Rachael C Aikens
- Department of Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Geoffrey Tso
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Christopher Sharp
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Neil K Shah
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
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Freedman RA, Revette AC, Gagnon H, Perilla-Glen A, Kokoski M, Hussein SO, Leone E, Hixon N, Lovato R, Loeser W, Lin NU, Minami CA, Canin B, LeStage B, Faggen M, Poorvu PD, McKenna J, Ruddy KJ, Keating NL, Schonberg MA. Acceptability of a companion patient guide to support expert consensus guidelines on surveillance mammography in older breast cancer survivors. Breast Cancer Res Treat 2022; 195:141-152. [PMID: 35908120 PMCID: PMC9362353 DOI: 10.1007/s10549-022-06676-3] [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: 03/11/2022] [Accepted: 07/04/2022] [Indexed: 11/04/2022]
Abstract
Purpose To support shared decision-making, patient-facing resources are needed to complement recently published guidelines on approaches for surveillance mammography in breast cancer survivors aged ≥ 75 or with < 10-year life expectancy. We created a patient guide to facilitate discussions about surveillance mammography in older breast cancer survivors. Methods The “Are Mammograms Still Right for Me?” guide estimates future ipsilateral and contralateral breast (in-breast) cancer risks, general health, and the potential benefits/harms of mammography, with prompts for discussion. We conducted in-clinic acceptability testing of the guide by survivors and their clinicians at a National Cancer Institute-designated comprehensive cancer center, including two community practices. Patients and clinicians received the guide ahead of a clinic visit and surveyed patients (pre-/post-visit) and clinicians (post-visit). Acceptability was defined as ≥ 75% of patients and clinicians reporting that the guide (a) should be recommended to others, (b) is clear, (c) is helpful, and (d) contains a suitable amount of information. We also elicited feedback on usability and mammography intentions. Results We enrolled 45 patients and their 21 clinicians. Among those responding in post-visit surveys, 33/37 (89%) patients and 15/16 (94%) clinicians would recommend the guide to others; 33/37 (89%) patients and 15/16 (94%) clinicians felt everything/most things were clear. All other pre-specified acceptability criteria were met. Most patients reported strong intentions for mammography (100% pre-visit, 98% post-visit). Conclusion Oncology clinicians and older breast cancer survivors found a guide to inform mammography decision-making acceptable and clear. A multisite clinical trial is needed to assess the guide’s impact mammography utilization. Trial registration: ClinicalTrials.gov-NCT03865654, posted March 7, 2019. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06676-3.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
| | - Anna C Revette
- Survey and Qualitative Methods Core for Qualitative and Quantitative Research, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Adriana Perilla-Glen
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Molly Kokoski
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Saida O Hussein
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Erin Leone
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nicole Hixon
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Rebeka Lovato
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Wendy Loeser
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Barbara LeStage
- Dana-Farber Cancer Institute, Boston, MA, USA.,Alliance for Clinical Trials in Oncology, Boston, MA, USA
| | - Meredith Faggen
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Philip D Poorvu
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Jennifer McKenna
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mara A Schonberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Abstract
In recent years, several trials of breast cancer treatment have failed to demonstrate a survival benefit for some previously routine surgical therapies in selected patient groups. As each of these therapeutic approaches has been deemed of low value deimplementation has varied significantly. This demonstrates that effective de-escalation in breast cancer surgery relies on more than the availability of data from randomized controlled trials and other high-quality evidence, but is also influenced by various stakeholders, social expectations, and environmental contexts.
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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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Affiliation(s)
| | - Ton Wang
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Reshma Jagsi
- Department of Radiation Oncology,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - Eve A Kerr
- Department of Internal Medicine , Center for Clinical Management Research, Ann Arbor, MI
| | - Lesly A Dossett
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
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13
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Powers B, Smith CD, Arroyo N, Francis DO, Fernandes-Taylor S. How Do Academic Otolaryngologists Decide to Implement New Procedures Into Practice? Otolaryngol Head Neck Surg 2021; 167:253-261. [PMID: 34546818 DOI: 10.1177/01945998211047434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify barriers and facilitators to adoption of a new surgical procedure via an implementation science framework to characterize associated socioemotional, clinical, and decision-making processes. STUDY DESIGN Qualitative study with a semistructured interview approach. SETTING Large tertiary care referral center. METHODS Academic otolaryngologists with at least 2 years of practice were identified and interviewed. Transcripts were thematically coded and separated into steps in the clinical pathway. Synthesis of major themes characterized facilitators and barriers to uptake of a new surgical technique. RESULTS Of 22 otolaryngologists, 19 were interviewed (85% male). They had a median 18 years of practice (interquartile range, 7.8-26.3), and 65% were subspecialty trained. In the decision to implement a new procedure, improving patient outcomes and addressing unmet clinical needs facilitated adoption, whereas costs and adopting profit-driven technologies without improved outcomes were barriers. In patient consults, establishing trust facilitated implementation of new techniques; barriers included participants' hesitation to communicate about the unknowns of a new procedure. Intraoperatively, little change to existing workflow or improved efficiency facilitated adoption, while a substantial learning curve for the new procedure was a barrier. Achieving favorable outcomes and patient satisfaction sustained implementation of new procedures. Too few referrals or indications for the new procedure hindered implementation. CONCLUSION Our study demonstrates that innovation in otolaryngology is often an individual iterative process that providers pursue to improve patients' outcomes. Although models for the oversight of surgical innovation emphasize the need for evidence, obtaining sufficient numbers of providers and patients to generate evidence remains a challenge in specialty surgical practice.
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Affiliation(s)
- Bethany Powers
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Cara Damico Smith
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - David O Francis
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
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14
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Nelson H. Reducing Cost of Care Through Deimplementation of Surgical Overtreatment. ANNALS OF SURGERY OPEN 2021; 2:e089. [PMID: 37635824 PMCID: PMC10455373 DOI: 10.1097/as9.0000000000000089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/18/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Heidi Nelson
- From the Division of Research and Optimal Patient Care, Cancer Department, American College of Surgeons, Chicago, IL
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15
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Johnson PT, Anzai Y. Radiology at the Helm of Value-Based Care Transformation: From Stewardship to Leadership. J Am Coll Radiol 2021; 18:1226-1228. [PMID: 34358461 DOI: 10.1016/j.jacr.2021.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Pamela T Johnson
- Vice President of Care Transformation, Johns Hopkins Health System; Vice Chair of Quality, Safety and Value in Radiology, Johns Hopkins Medicine; Professor of Radiology, Oncology and Urology, Johns Hopkins University School of Medicine; Co-Founder and Co-Director, High Value Practice Academic Alliance; Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland.
| | - Yoshimi Anzai
- Associate Chief Medical Quality Officer, University of Utah HealthCare; Professor of Radiology, Co-director, High Value Practice Academic Alliance Radiology Collaborative; Department of Radiology and Imaging Services, University of Utah, Salt Lake City, Utah
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16
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Roberts GP, Levy N, Lobo DN. Patient-centric goal-oriented perioperative care. Br J Anaesth 2021; 126:559-564. [PMID: 33419527 DOI: 10.1016/j.bja.2020.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 01/17/2023] Open
Affiliation(s)
- Geoffrey P Roberts
- Department of Surgery, West Suffolk NHS Foundation Trust, Bury St. Edmunds, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St. Edmunds, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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17
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Affiliation(s)
- Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI
- University of Michigan, Institute for Health Policy and Innovation (IHPI), Ann Arbor, MI
| | - Michael S Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI
- University of Michigan, Institute for Health Policy and Innovation (IHPI), Ann Arbor, MI
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18
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Baskin AS, Wang T, Bredbeck BC, Sinco BR, Berlin NL, Dossett LA. Trends in Contralateral Prophylactic Mastectomy Utilization for Small Unilateral Breast Cancer. J Surg Res 2021; 262:71-84. [PMID: 33548676 DOI: 10.1016/j.jss.2020.12.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/01/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND For average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and patient harm. Despite recommendations from professional societies against CPM, utilization of this service is increasing, partly due to patients' desire for breast symmetry when undergoing mastectomy. Most women with small tumors are candidates for breast-conserving surgery (BCS) and could avoid CPM. We describe CPM utilization in women with small, unilateral tumors, and identify determinants of possible overuse. METHODS Using the National Cancer Database, we identified women with unilateral, T1 breast cancer. We evaluated utilization of BCS, unilateral mastectomy, and CPM and assessed patient, tumor, and facility factors associated with CPM. RESULTS Of 765,487 women with small, unilateral breast cancer, 69% underwent BCS and 31% chose mastectomy. Of 176,673 women ≥70 y, 75% underwent BCS and 25% chose mastectomy. CPM rates in both cohorts have increased since 2006. Decreased adjuvant radiotherapy in older women was associated with increased BCS rates. Patient factors (younger age, white race, private insurance, and breast reconstruction), tumor factors (lobular histology, higher grade, and human epidermal growth factor receptor 2 positive/estrogen receptor negative status), and facility factors (type and geographic location) were associated with increased CPM rates compared with unilateral mastectomy in multivariable models. CONCLUSIONS Most women with small unilateral breast cancer are candidates for BCS, yet one-third elects to undergo a mastectomy, of which a rising percentage opts for CPM. Tailoring deimplementation strategies to factors influencing treatment may help reduce CPM utilization and associated financial toxicity, pain, and disability.
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Affiliation(s)
| | - Ton Wang
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brooke C Bredbeck
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brandy R Sinco
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Nicholas L Berlin
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Levy N, Selwyn DA, Lobo DN. Turning 'waiting lists' for elective surgery into 'preparation lists'. Br J Anaesth 2021; 126:1-5. [PMID: 32900503 DOI: 10.1016/j.bja.2020.08.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/31/2020] [Accepted: 08/17/2020] [Indexed: 01/02/2023] Open
Affiliation(s)
- Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St. Edmunds, UK
| | - David A Selwyn
- Centre for Perioperative Care (CPOC), Churchill House, London, UK; Department of Critical Care, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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20
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Demand for Surgical Procedures Following COVID-19: The Need for Operational Strategies That Optimize Resource Utilization and Value. Ann Surg 2020; 272:e272-e274. [PMID: 32932326 DOI: 10.1097/sla.0000000000004366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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