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Bosserman LD, Mambetsariev I, Ladbury C, Barzi A, Johnson D, Morse D, Deaville D, Smith W, Rajurkar S, Merla A, Hajjar G, Kim D, Fricke J, Trisal V, Salgia R. Pyramidal Decision Support Framework Leverages Subspecialty Expertise across Enterprise to Achieve Superior Cancer Outcomes and Personalized, Precision Care Plans. J Clin Med 2022; 11:jcm11226738. [PMID: 36431215 PMCID: PMC9697355 DOI: 10.3390/jcm11226738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
The complexity of cancer care requires integrated and continuous support to deliver appropriate care. An expert network with complementary expertise and the capability of multidisciplinary care is an integral part of contemporary oncology care. Appropriate infrastructure is necessary to empower this network to deliver personalized precision care to their patients. Providing decision support as cancer care becomes exponentially more complex with new diagnostic and therapeutic choices remains challenging. City of Hope has developed a Pyramidal Decision Support Framework to address these challenges, which were exacerbated by the COVID pandemic, health plan restrictions, and growing geographic site diversity. Optimizing efficient and targeted decision support backed by multidisciplinary cancer expertise can improve individual patient treatment plans to achieve improved care and survival wherever patients are treated.
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Affiliation(s)
- Linda D. Bosserman
- Department of Medical Oncology and Therapeutics Research, City of Hope, Irwindale, CA 91706, USA
| | - Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope, Duarte, CA 91010, USA
| | - Afsaneh Barzi
- Department of Medical Oncology and Therapeutics Research, City of Hope, Irwindale, CA 91706, USA
| | - Deron Johnson
- Department of Clinical Informatics, City of Hope, Duarte, CA 91010, USA
| | - Denise Morse
- Department of Quality, Risk and Regulatory Management, City of Hope, Duarte, CA 91010, USA
| | - Debbie Deaville
- Department of Enterprise Business Intelligence, City of Hope, Irwindale, CA 91706, USA
| | - Wade Smith
- Department of Medical Oncology and Therapeutics Research, City of Hope, Newport Beach, CA 92660, USA
| | - Swapnil Rajurkar
- Department of Medical Oncology and Therapeutics Research, City of Hope, Upland, CA 91784, USA
| | - Amartej Merla
- Department of Medical Oncology and Therapeutics Research, City of Hope, Antelope Valley, CA 93534, USA
| | - George Hajjar
- Department of Medical Oncology and Therapeutics Research, City of Hope, Mission Hills, CA 91345, USA
| | - Daniel Kim
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Jeremy Fricke
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Vijay Trisal
- Department of Medicine, City of Hope, Duarte, CA 91010, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
- Correspondence:
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Alishahi Tabriz A, Turner K, Clary A, Hong YR, Nguyen OT, Wei G, Carlson RB, Birken SA. De-implementing low-value care in cancer care delivery: a systematic review. Implement Sci 2022; 17:24. [PMID: 35279182 PMCID: PMC8917720 DOI: 10.1186/s13012-022-01197-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 02/14/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Accumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings. METHODS We systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus from 1 January 1990 to 4 March 2021. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies' key characteristics including design, type of cancer, outcome(s), objective(s), de-implementation interventions description, and determinants of the de-implementation interventions. To extract the data, pairs of authors placed text from included articles into the appropriate cells within our framework. We analyzed extracted data from each cell to describe the studies and findings of de-implementation interventions aiming to reduce low-value cancer care. RESULTS Out of 2794 studies, 12 met our inclusion criteria. The studies covered several cancer types, including prostate cancer (n = 5), gastrointestinal cancer (n = 3), lung cancer (n = 2), breast cancer (n = 2), and hematologic cancers (n = 1). Most of the interventions (n = 10) were multifaceted. Auditing and providing feedback, having a clinical champion, educating clinicians through developing and disseminating new guidelines, and developing a decision support tool are the common components of the de-implementation interventions. Six of the de-implementation interventions were effective in reducing low-value care, five studies reported mixed results, and one study showed no difference across intervention arms. Eleven studies aimed to de-implement low-value care by changing providers' behavior, and 1 de-implementation intervention focused on changing the patients' behavior. Three studies had little risk of bias, five had moderate, and four had a high risk of bias. CONCLUSIONS This review demonstrated a paucity of evidence in many areas of the de-implementation of low-value care including lack of studies in active de-implementation (i.e., healthcare organizations initiating de-implementation interventions purposefully aimed at reducing low-value care).
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Affiliation(s)
- Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 4115 E. Fowler Avenue, Tampa, FL 33617 USA
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 4115 E. Fowler Avenue, Tampa, FL 33617 USA
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Alecia Clary
- The Reagan-Udall Foundation for the FDA, 1900 L Street, NW, Suite 835, Washington, DC, 20036 USA
| | - Young-Rock Hong
- UF Health Cancer Center, Gainesville, FL USA
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, HPNP Building, Room 3111, Gainesville, FL 32610 USA
| | - Oliver T. Nguyen
- Department of Community Health & Family Medicine, University of Florida, P.O. Box 100211, Gainesville, FL 32610 USA
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL USA
| | - Grace Wei
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Rebecca B. Carlson
- Health Sciences Library, The University of North Carolina at Chapel Hill, 335 S. Columbia Street, Chapel Hill, NC 27599 USA
| | - Sarah A. Birken
- Department of Implementation Science, Wake Forest School of Medicine, 525@Vine Room 5219, Medical Center Boulevard, Winston-Salem, NC 27157 USA
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Affiliation(s)
- Katharine A Rendle
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104,USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104,USA
| | - Rinad S Beidas
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104,USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104,USA
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104,USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Implementation Science Center at the Leonard Davis Institute (PISCE@LDI), University of Pennsylvania, Philadelphia, PA 19104,USA
- Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA 19104, USA
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Austin JD, Tehranifar P, Rodriguez CB, Brotzman L, Agovino M, Ziazadeh D, Moise N, Shelton RC. A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation. Implement Sci Commun 2021; 2:110. [PMID: 34565481 PMCID: PMC8474751 DOI: 10.1186/s43058-021-00217-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/14/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse. METHODS This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process. RESULTS Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening. CONCLUSIONS Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.
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Affiliation(s)
- Jessica D Austin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA
| | - Parisa Tehranifar
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Carmen B Rodriguez
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Laura Brotzman
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Mariangela Agovino
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Danya Ziazadeh
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Nathalie Moise
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA.
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA.
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