Examining the Causes of Continued Use of Low-Value Breast Cancer Surgeries

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Deimplementation is defined as the science of eliminating low-value medical practices using evidence-based processes.1,2 By deimplementing inappropriate health interventions, population health may be enhanced by preserving public trust, reducing patient harm, and decreasing waste. Recently, investigators, academics, healthcare professionals, funders, legislators, and patients have concentrated on the necessity of preventing or mitigating the use of inappropriate health procedures.1

To encourage the deimplementation of low-value healthcare services, the American Board of Internal Medicine Foundation created the Choosing Wisely campaign to detect unnecessary medical and surgical services.

Focusing on 4 low-value breast cancer operations identified through the Choosing Wisely campaign (axillary lymph node dissection, lumpectomy reoperation, contralateral prophylactic mastectomy, and sentinel lymph node biopsy), researchers sought to uncover factors contributing to the persistent use of low-value breast cancer surgical care.

Data exist on patient-level and clinician-level determinants of continued overuse and suggest varying rates of deimplementation. However, there is a lack of information about variation between facilities or factors contributing to differential deimplementation.

In a retrospective cohort study, researchers used random-intercept hierarchical logistic regression to calculate reliability-adjusted facility rates for each procedure before and after they were designated as unnecessary.

Gleaned from >1500 institutions across the United States, the National Cancer Database (NCD) is a prospective cancer registry of patients that has data on roughly 70% of all new cancer diagnoses.

For the study, researchers analyzed NCD data from November 2019 to August 2020, focusing on data from women who were aged ≥18 years, diagnosed with breast cancer between 2004 and 2016, and met inclusion criteria for the 4 Choosing Wisely procedures. They tracked the rates of all low-value breast cancer procedures, based on facility type and breast cancer volume categories, before and after the release of data supporting each procedure’s omission.

A total of 920,256 women were included in the analysis, with a median age of 63 years. Overall, 86% of patients included in the study self-identified as white, 3% identified as Asian, 4.5% identified as Hispanic, and 10% identified as black. The study population consisted of mostly women who were insured, with 51% having private insurance and 47% having public insurance. The majority of patients included in the analysis inhabited a metropolitan area (88%) or urban region (11%), and 65.5% were from the top half of income-earning households.

Although the researchers reported “significant” deimplementation of axillary lymph node dissection and lumpectomy reoperation, in keeping with guidelines supporting omission of these procedures, they found that during the study period the rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased.

In general, the greatest reduction in use of these low-value procedures occurred at academic research programs and high-volume facilities. There was little consistency; for each low-value procedure, there was significant interfacility variation.

Rates for procedures ranged significantly. Facility-level axillary lymph node dissection rates varied from 7% to 47%, lumpectomy reoperation 3% to 62%, contralateral prophylactic mastectomy 9% to 67%, and sentinel lymph node biopsy 25% to 97%. Hospitals were inconsistent in their deimplementation performance across all 4 procedures; many were low outliers in one procedure but high outliers in other procedures.

The researchers concluded that the discrepancies in deimplementation rates between facilities are indicative of a knowledge gap and present an opportunity for the development of guideline-supported deimplementation protocols for each low-value procedure.

Source

Wang T, Bredbeck BC, Sinco B, et al. Variations in persistent use of low-value breast cancer surgery. JAMA Surg. Published online ahead of print February 3, 2021. 2021;e206942.

References

  1. Norton WE, Chambers DA. Unpacking the complexities of de-implementing inappropriate health interventions. Implement Sci. 2020;15:2.
  2. Grimshaw JM, Patey AM, Kirkham KR, et al. De-implementing wisely: developing the evidence base to redue low-value care. BMJ Qual Saf. 2020;29:409-417.

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