16 Study Notes on De-Implementing Ineffective Clinical Practices in Oncology
Introduction
Authors: Wynne E. Norton, PhD; Worta McCaskill-Stevens, MD; David A. Chambers, DPhil; Philip J. Stella, MD; Otis W. Brawley, MD; Barnett S. Kramer, MD, MPH
Affiliations: Division of Cancer Control and Population Sciences, National Cancer Institute; Division of Cancer Prevention, National Cancer Institute; St Joseph Mercy Hospital; Johns Hopkins University.
Correspondence: Wynne E. Norton, PhD, National Cancer Institute.
Abstract
Concern over ineffective or low-value clinical practices in cancer care is growing among patients, practitioners, and policy makers.
There is a need for research to determine how to effectively deimplement these practices.
The National Cancer Institute Community Oncology Research Program (NCORP) is highlighted as an ideal infrastructure for conducting research on deimplementation.
Discussion of issues affecting deimplementation strategies and study designs to test these strategies.
Importance of NCORP in improving cancer care delivery while addressing patient needs nationwide.
Context of increasing recognition of ineffective practices in oncology and the financial toxicity associated with them.
Importance of Deimplementation in Cancer Care
Factors that contribute to waste and overuse in health care delivery, particularly in oncology.
Mention of educational campaigns, waste reports, and medical reversals driving recognition of ineffective practices.
Example trials:
Trial Assigning Individualized Options for Treatment: identified chemotherapy may not be necessary for certain patients.
Study by Venook et al.: no benefit yet higher costs when comparing certain chemotherapeutic interventions.
Shift needed from focusing solely on describing ineffective practices to actively deimplementing them.
Key Concepts in De-Implementation
Definition: Deimplementation is a complex process that includes various actions (removing, replacing, reducing, restricting) and is influenced by multilevel barriers and strategies.
Challenges in deimplementation include:
Going against established beliefs and policies that promote existing practices.
Patient reluctance to forego often unnecessary screenings or treatments despite evidence against their efficacy.
Societal norms favoring more care.
Examples:
Over-screening in elderly patients despite guidelines: 45% overscreened based on a study of 175,000 individuals.
Patient preferences for advanced, costly procedures despite recommendations against them.
Evidence gap on effective deimplementation strategies and their impact.
De-Implementation in Community Oncology Care Settings
Deimplementation trials should reflect diverse patient populations and contexts typical of community settings.
NCORP as a national network positioned to execute deimplementation research.
Structure of NCORP: 32 community oncology sites, 1017 affiliated organizations, 14 targeted minority or underserved sites.
Broad geographic coverage enhances participant diversity.
Current research portfolio includes over 100 studies on numerous oncology-related topics.
Advantages of NCORP for De-Implementation Research
Extensive network supports large trials required for methodological rigor and generalizability.
Community-based focus helps foster practitioner-centered and patient-centered research frameworks.
Potential for increased health equity and reduced care disparities through broader patient and provider involvement.
Rigorous Designs for De-Implementation
Importance of choosing appropriate study designs for testing deimplementation strategies.
Recommended designs:
Cluster RCTs: randomization at the organization level (e.g., hospital or clinic) to minimize contamination between conditions.
Acknowledgment of validity vs. generalizability concerns in traditional RCTs.
Pragmatic RCTs: designed to assess effectiveness in routine clinical settings, addressing real-world applicability.
Use of the PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) for trial design.
Opportunities for De-Implementation Trials in NCORP
Identification of practices from the Choosing Wisely campaign that could benefit from deimplementation attempts.
Presentation of specific strategies for trials, such as variations in audit feedback and changes to electronic health record order sets.
Alternative designs like quasi-experimental studies for situations where RCTs may not be feasible.
Qualitative and Mixed-Methods Approaches
Qualitative methods (e.g., semi-structured interviews) can reveal barriers to deimplementation and inform strategies.
Mixed-methods studies allow integration of qualitative and quantitative data, enhancing understanding of deimplementation processes.
Conclusion
The necessity for effective deimplementation strategies in oncology is emphasized.
NCORP as a valuable infrastructure for advancing research in deimplementation and clinical practice change to optimize patient outcomes.
Importance of fostering research-practice partnerships and utilizing available resources to enhance deimplementation efforts in the community.
Funding and Disclosures
No additional funding reported.
No competing interests disclosed by most authors, with one author reporting consulting for Genentech-Roche.
Authors: Wynne E. Norton, PhD; Worta McCaskill-Stevens, MD; David A. Chambers, DPhil; Philip J. Stella, MD; Otis W. Brawley, MD; Barnett S. Kramer, MD, MPH
Affiliations: Division of Cancer Control and Population Sciences, National Cancer Institute; Division of Cancer Prevention, National Cancer Institute; St Joseph Mercy Hospital; Johns Hopkins University.
Correspondence: Wynne E. Norton, PhD, National Cancer Institute.
Abstract
Concern over ineffective or low-value clinical practices in cancer care is growing among patients, practitioners, and policy makers. This concern has led to collective efforts to identify and minimize such practices across various healthcare systems.
There is a need for research to determine how to effectively deimplement these practices, including understanding obstacles and facilitators that exist at multiple levels including individual, organizational, and systemic.
The National Cancer Institute Community Oncology Research Program (NCORP) is highlighted as an ideal infrastructure due to its extensive networks and experience in community-based research, making it well-suited for conducting research on deimplementation.
Discussion includes issues affecting deimplementation strategies, methods of study designs to test these strategies, and relevant metrics for evaluating their success.
Importance of NCORP in improving cancer care delivery while addressing patient needs nationwide, especially those of marginalized communities who often experience barriers to access and support.
Context of increasing recognition of ineffective practices in oncology and the financial toxicity associated with them, prompting a shift towards value-based care that prioritizes patient wellbeing and cost-effectiveness.
Importance of Deimplementation in Cancer Care
Factors that contribute to waste and overuse in health care delivery, particularly in oncology, include misaligned incentives, lack of awareness, and historical precedent favoring aggressive treatment approaches.
Mention of educational campaigns, waste reports, and medical reversals driving recognition of ineffective practices, which can lead to improved clinical guidelines and enhanced patient outcomes over time.
Example trials:
Trial Assigning Individualized Options for Treatment: identified that chemotherapy may not be necessary for certain patients, emphasizing the importance of personalized medicine.
Study by Venook et al.: demonstrated no benefit and higher costs when comparing certain chemotherapeutic interventions, suggesting a re-evaluation of treatment protocols to better align with current evidence.
Shift needed from focusing solely on describing ineffective practices to actively deimplementing them in order to improve overall healthcare efficiencies and patient satisfaction.
Introduction
Authors: Wynne E. Norton, PhD; Worta McCaskill-Stevens, MD; David A. Chambers, DPhil; Philip J. Stella, MD; Otis W. Brawley, MD; Barnett S. Kramer, MD, MPH
Affiliations: Division of Cancer Control and Population Sciences, National Cancer Institute; Division of Cancer Prevention, National Cancer Institute; St Joseph Mercy Hospital; Johns Hopkins University.
Correspondence: Wynne E. Norton, PhD, National Cancer Institute.
Abstract
Concern over ineffective or low-value clinical practices in cancer care is growing among patients, practitioners, and policy makers. This concern has led to collective efforts to identify and minimize such practices across various healthcare systems.
There is a need for research to determine how to effectively deimplement these practices, including understanding obstacles and facilitators that exist at multiple levels including individual, organizational, and systemic.
The National Cancer Institute Community Oncology Research Program (NCORP) is highlighted as an ideal infrastructure due to its extensive networks and experience in community-based research, making it well-suited for conducting research on deimplementation.
Discussion includes issues affecting deimplementation strategies, methods of study designs to test these strategies, and relevant metrics for evaluating their success.
Importance of NCORP in improving cancer care delivery while addressing patient needs nationwide, especially those of marginalized communities who often experience barriers to access and support.
Context of increasing recognition of ineffective practices in oncology and the financial toxicity associated with them, prompting a shift towards value-based care that prioritizes patient wellbeing and cost-effectiveness.
Importance of Deimplementation in Cancer Care
Factors that contribute to waste and overuse in health care delivery, particularly in oncology, include misaligned incentives, lack of awareness, and historical precedent favoring aggressive treatment approaches.
Mention of educational campaigns, waste reports, and medical reversals driving recognition of ineffective practices, which can lead to improved clinical guidelines and enhanced patient outcomes over time.
Example trials:
Trial Assigning Individualized Options for Treatment: identified that chemotherapy may not be necessary for certain patients, emphasizing the importance of personalized medicine.
Study by Venook et al.: demonstrated no benefit and higher costs when comparing certain chemotherapeutic interventions, suggesting a re-evaluation of treatment protocols to better align with current evidence.
Shift needed from focusing solely on describing ineffective practices to actively deimplementing them in order to improve overall healthcare efficiencies and patient satisfaction.
Key Concepts in De-Implementation
Definition: Deimplementation is a complex process that includes various actions (removing, replacing, reducing, restricting) and is influenced by multilevel barriers and strategies.
Challenges in deimplementation include:
Going against established beliefs and policies that promote existing practices.
Patient reluctance to forego often unnecessary screenings or treatments despite evidence against their efficacy.
Societal norms favoring more care.
Examples:
Over-screening in elderly patients despite guidelines: 45% overscreened based on a study of 175,000 individuals.
Patient preferences for advanced, costly procedures despite recommendations against them.
Evidence gap on effective deimplementation strategies and their impact.
De-Implementation in Community Oncology Care Settings
Deimplementation trials should reflect diverse patient populations and contexts typical of community settings.
NCORP as a national network positioned to execute deimplementation research.
Structure of NCORP: 32 community oncology sites, 1017 affiliated organizations, 14 targeted minority or underserved sites.
Broad geographic coverage enhances participant diversity.
Current research portfolio includes over 100 studies on numerous oncology-related topics.
Advantages of NCORP for De-Implementation Research
Extensive network supports large trials required for methodological rigor and generalizability.
Community-based focus helps foster practitioner-centered and patient-centered research frameworks.
Potential for increased health equity and reduced care disparities through broader patient and provider involvement.
Rigorous Designs for De-Implementation
Importance of choosing appropriate study designs for testing deimplementation strategies.
Recommended designs:
Cluster RCTs: randomization at the organization level (e.g., hospital or clinic) to minimize contamination between conditions.
Acknowledgment of validity vs. generalizability concerns in traditional RCTs.
Pragmatic RCTs: designed to assess effectiveness in routine clinical settings, addressing real-world applicability.
Use of the PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) for trial design.
Opportunities for De-Implementation Trials in NCORP
Identification of practices from the Choosing Wisely campaign that could benefit from deimplementation attempts.
Presentation of specific strategies for trials, such as variations in audit feedback and changes to electronic health record order sets.
Alternative designs like quasi-experimental studies for situations where RCTs may not be feasible.
Qualitative and Mixed-Methods Approaches
Qualitative methods (e.g., semi-structured interviews) can reveal barriers to deimplementation and inform strategies.
Mixed-methods studies allow integration of qualitative and quantitative data, enhancing understanding of deimplementation processes.
Conclusion
The necessity for effective deimplementation strategies in oncology is emphasized.
NCORP as a valuable infrastructure for advancing research in deimplementation and clinical practice change to optimize patient outcomes.
Importance of fostering research-practice partnerships and utilizing available resources to enhance deimplementation efforts in the community.
Funding and Disclosures
No additional funding reported.
No competing interests disclosed by most authors, with one author reporting consulting for Genentech-Roche.
Authors: Wynne E. Norton, PhD; Worta McCaskill-Stevens, MD; David A. Chambers, DPhil; Philip J. Stella, MD; Otis W. Brawley, MD; Barnett S. Kramer, MD, MPH
Affiliations: Division of Cancer Control and Population Sciences, National Cancer Institute; Division of Cancer Prevention, National Cancer Institute; St Joseph Mercy Hospital; Johns Hopkins University.
Correspondence: Wynne E. Norton, PhD, National Cancer Institute.