Deimplementation of Ineffective and Harmful Medical Practices: A Data-Driven Commentary.

Deimplementation is the discontinuation or abandonment of medical practices that are ineffective or of unclear effectiveness, ranging from simply unhelpful to harmful. With epidemiology expanding to include more translational sciences, epidemiologists can contribute to deimplementation through defining evidence, establishing causality, and advising on study design. An estimated 10-30% of healthcare practices have minimal to no benefit to patients and should be targeted for deimplementation. The steps in deimplementation are: 1) identify low-value clinical practices, 2) facilitate the deimplementation process, 3) evaluate deimplementation outcomes, and 4) sustain deimplementation, each of which is a complex project. Deimplementation science involves researchers, healthcare and clinical stakeholders, and patient and community partners affected by the medical practice. Increasing collaboration between epidemiologists and implementation scientists is important to optimizing health care delivery.

Factors Affecting Post-trial Sustainment or De-implementation of Study Interventions: A Narrative Review.

In contrast to traditional randomized controlled trials, embedded pragmatic clinical trials (ePCTs) are conducted within healthcare settings with real-world patient populations. ePCTs are intentionally designed to align with health system priorities leveraging existing healthcare system infrastructure and resources to ease intervention implementation and increase the likelihood that effective interventions translate into routine practice following the trial. The NIH Pragmatic Trials Collaboratory, funded by the National Institutes of Health (NIH), supports the conduct of large-scale ePCT Demonstration Projects that address major public health issues within healthcare systems. The Collaboratory has a unique opportunity to draw on the Demonstration Project experiences to generate lessons learned related to ePCTs and the dissemination and implementation of interventions tested in ePCTs. In this article, we use case studies from six completed Demonstration Projects to summarize the Collaboratory's experience with post-trial interpretation of results, and implications for sustainment (or de-implementation) of tested interventions. We highlight three key lessons learned. First, ineffective interventions (i.e., ePCT is null for the primary outcome) may be sustained if they have other measured benefits (e.g., secondary outcome or subgroup) or even perceived benefits (e.g., staff like the intervention). Second, effective interventions-even those solicited by the health system and/or designed with significant health system partner buy-in-may not be sustained if they require significant resources. Third, alignment with policy incentives is essential for achieving sustainment and scale-up of effective interventions. Our experiences point to several recommendations to aid in considering post-trial sustainment or de-implementation of interventions tested in ePCTs: (1) include secondary outcome measures that are salient to health system partners; (2) collect all appropriate data to allow for post hoc analysis of subgroups; (3) collect experience data from clinicians and staff; (4) engage policy-makers before starting the trial.

Behavioral Interventions on Surgeons' Preoperative Decision-Making: A Scoping Review and Critical Analysis.

INTRODUCTION: Consensus is lacking regarding the optimal strategy to influence surgeons' behaviors to reduce low-value surgical care. Comprehensively describing the existing body of literature that seeks to intervene on surgeons' preoperative decision-making may aid in structuring future behavior change strategies. METHODS: We performed a scoping review using four databases (Medical Literature Analysis and Retrieval System Online, Embase, Web of Science, and Cumulated Index to Nursing and Allied Health Literature) for articles that tested the effect of behavioral-based interventions on any aspect of surgeons' decision-making in the preoperative setting. Abstracted data were characterized by summative descriptions and analyzed using the Tailored Implementation for Chronic Disease framework, mapping aspects of deimplementation strategies in the studies onto the determinant(s) that they altered. Data abstraction and mapping tools were piloted and iteratively revised before two researchers independently assessing studies and categorizing determinants, and then meeting to discuss their decisions. RESULTS: There were 1460 articles identified from the initial search, with 17 full text articles ultimately included in the scoping review. Eight studies relied on a multidisciplinary preoperative conference to accomplish their aims, while five were multifaceted in their approach to deimplementation, and four studies used only a clinical decision support tool to accomplish their aims. Mapping determinants addressed in these studies onto the Tailored Implementation for Chronic Disease framework demonstrated that most strategies attempted to close knowledge gaps, leverage communication between providers, and broadcast institutional prioritization of change. CONCLUSIONS: There is a small but growing field of implementation and deimplementation strategies in preoperative surgical decision-making, and different approaches may be equally effective in varied clinical contexts. Deliberate measurement and comparison of outcomes, as well as selection of control groups, are areas for improvement in future work.

Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study.

INTRODUCTION: Despite multispecialty recommendations to avoid routine preoperative testing before low-risk surgery, the practice remains common and de-implementation has proven difficult. The goal of this study as to elicit determinants of unnecessary testing before low-risk surgery to inform de-implementation efforts. METHODS: We conducted focused ethnography at a large academic institution, including semi-structured interviews and direct observations at two preoperative evaluation clinics and one outpatient surgery center. Themes were identified through narrative thematic analysis and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Diseases framework (TICD). RESULTS: Thirty individuals participated (surgeons, anesthesiologists, primary care physicians, physician assistants, nurses, and medical assistants). Three themes were identified: (1) Shared Values (TICD Social, Political, and Legal Factors), (2) Gaps in Knowledge (TICD Individual Health Professional Factors, Guideline Factors), and (3) Communication Breakdown (TICD Professional Interactions, Incentives and Resources, Capacity for Organizational Change). Shared Values describe core tenets expressed by all groups of clinicians, namely prioritizing patient safety and utilizing evidence-based medicine. Clinicians had Gaps in Knowledge related to existing data and preoperative testing recommendations. Communication Breakdowns within interdisciplinary teams resulted in unnecessary testing ordered to meet perceived expectations of other providers. CONCLUSIONS: Clinicians have knowledge gaps related to preoperative testing recommendations and may be amenable to de-implementation efforts and educational interventions. Consensus guidelines may streamline interdisciplinary communication by clarifying interdisciplinary needs and reducing testing ordered to meet perceived expectations of other clinicians.

Understanding Treatment Decision-Making in Older Women With Breast Cancer: A Survey-Based Study.

INTRODUCTION: For women ≥70 y old with early-stage hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer, the national guidelines recommend the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy. However, national-level data suggest these treatments remain common. We utilized a survey-based approach to explore patient-level factors driving overutilization. METHODS: We recruited women ≥70 y old with early-stage hormone receptor-positive/human epidermal growth factor receptor 2-negative breast cancer within 6 mo of surgery. An exploratory cross-sectional survey captured information on offered and pursued treatments, the importance of patient-centered outcomes, and the influence of each outcome on treatment decision-making. Descriptive statistics were used for analysis. RESULTS: 31/51 patients completed the survey with a response rate of 61%. Most patients (86%) received a lumpectomy. Twenty-eight percent of patients received SLNB, and 56% of lumpectomy patients underwent adjuvant radiotherapy. When considering treatment options, the patient-centered outcomes, most important for decision-making, were overall survival, breast-specific survival, and preventing local recurrence, while breast appearance, financial costs, and avoiding the need for pills (endocrine therapy) were the least important. CONCLUSIONS: Patients' treatment decisions align with their values. The correlation between patient-stated values and treatment decisions suggests a perceived mortality benefit of low-value SLNB and radiotherapy. These findings can inform targeted efforts to deimplement low-value care in breast cancer through patient-focused tools and education.

The deimplementation of laboratory testing in low-risk patients as recommended by the American society of anesthesiologists: An ACS-NSQIP longitudinal analysis.

BACKGROUND: In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low-risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low-risk versus higher-risk patients before and after release of these guidelines. METHODS: The ACS-NSQIP database, 2005-2018, was separated into low-risk versus higher-risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low- and higher-risk patients. A difference-in-differences model was applied. The primary outcome included any laboratory test obtained ≤90 days prior to surgery. RESULTS: Of 7,507,991 patients, 972,431 (13.0%) were defined as low-risk and 6,535,560 (87.0%) higher-risk. Use of any preoperative laboratory test declined in low-risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%-91.9% in higher-risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk-adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76-0.78) in low-risk versus 0.93 (0.92-0.94) in higher-risk patients. In low-risk patients, lack of any preoperative testing was not associated with worse outcomes. CONCLUSIONS: While a majority of low-risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low-risk patients.

Understanding the uptake and adaption of targeted implementation interventions for reducing bronchiolitis investigations and therapies.

AIM: To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments. METHODS: A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made. RESULTS: Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation. CONCLUSION: Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.

PRO: Implementation Science Has Value in Anesthesiology and Cardiothoracic Surgery.

Implementation science is a nascent field that aims to study the factors that influence the effectiveness of a given clinical intervention, such as the characteristics of the individuals involved, the internal and external settings, the process of implementation, and other factors. Overall, implementation science aims to increase the extent to which an intervention is practiced, and the quality of its delivery to a patient. Although still in its infancy, the applications of implementation science in anesthesiology and cardiothoracic surgery abound. Whether used to adopt novel innovations, avoid the use of obsolete practices, or redeploy existing interventions to improve quality, implementation science holds promise in optimizing how we bring the latest in clinical science to produce tangible benefits to patients and create sustainable change.

Barriers and facilitators for reducing low-value home-based nursing care: A qualitative exploratory study among homecare professionals.

AIM: To explore barriers and facilitators for reducing low-value home-based nursing care. DESIGN: Qualitative exploratory study. METHOD: Seven focus group interviews and two individual interviews were conducted with homecare professionals, managers and quality improvement staff members within seven homecare organizations. Data were deductively analysed using the Tailored Implementation for Chronic Diseases checklist. RESULTS: Barriers perceived by homecare professionals included lack of knowledge and skills, such as using care aids, interactions between healthcare professionals and general practitioners creating expectations among clients. Facilitators perceived included reflecting on provided care together with colleagues, clearly communicating agreements and expectations towards clients. Additionally, clients' and relatives' behaviour could potentially hinder reduction. In contrast, clients' motivation to be independent and involving relatives can promote reduction. Lastly, non-reimbursement and additional costs of care aids were perceived as barriers. Support from organization and management for the reduction of care was considered as facilitator. CONCLUSION: Understanding barriers and facilitators experienced by homecare professionals in reducing low-value home-based nursing care is crucial. Enhancing knowledge and skills, fostering cross-professional collaboration, involving relatives and motivating clients' self-care can facilitate reduction of low-value home-based nursing care. Implications for profession and patient care: De-implementing low-value home-based nursing care offers opportunities for more appropriate care and inclusion of clients on waitlists. IMPACT: Addressing barriers with tailored strategies can successfully de-implement low-value home-based nursing care. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research checklist was used. No patient or public contribution.

Low-value home-based nursing care: A national survey study.

AIMS: To explore potential areas of low-value home-based nursing care practices, their prevalence and related influencing factors of nurses and nursing assistants working in home-based nursing care. DESIGN: A quantitative, cross-sectional design. METHODS: An online survey with questions containing scaled frequencies on five-point Likert scales and open questions on possible related influencing factors of low-value nursing care. The data collection took place from February to April 2022. Descriptive statistics and linear regression were used to summarize and analyse the results. RESULTS: A nationwide sample of 776 certified nursing assistants, registered nurses and nurse practitioners responded to the survey. The top five most delivered low-value care practices reported were: (1) 'washing the client with water and soap by default', (2) 'application of zinc cream, powders or pastes when treating intertrigo', (3) 'washing the client from head to toe daily', (4) 're-use of a urinary catheter bag after removal/disconnection' and (5) 'bladder irrigation to prevent clogging of urinary tract catheter'. The top five related influencing factors reported were: (1) 'a (general) practitioner advices/prescribes it', (2) 'written in the client's care plan', (3) 'client asks for it', (4) 'wanting to offer the client something' and (5) 'it is always done like this in the team'. Higher educational levels and an age above 40 years were associated with a lower provision of low-value care. CONCLUSION: According to registered nurses and certified nursing assistants, a number of low-value nursing practices occurred frequently in home-based nursing care and they experienced multiple factors that influence the provision of low-value care such as (lack of) clinical autonomy and handling clients' requests, preferences and demands. The results can be used to serve as a starting point for a multifaceted de-implementation strategy. REPORTING METHOD: STROBE checklist for cross-sectional studies. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Nursing care is increasingly shifting towards the home environment. Not all nursing care that is provided is effective or efficient and this type of care can therefore be considered of low-value. Reducing low-value care and increasing appropriate care will free up time, improve quality of care, work satisfaction, patient safety and contribute to a more sustainable healthcare system.

Testing Theory-Based Messages to Encourage Women at Average Risk for Breast Cancer to Consider Biennial Mammography Screening.

BACKGROUND: The US Preventive Services Task Force does not recommend routine annual mammography screening for women aged 40-49 at average risk. Little research has been done to develop theory-based communication interventions to facilitate informed decision-making about reducing potentially low-value mammography screening. PURPOSE: Evaluate the effects of theory-based persuasive messages on women's willingness to consider delaying screening mammography until age 50 or have mammograms biennially. METHODS: We conducted a randomized controlled communication experiment online with a population-based sample of U.S. women aged 40-49 (N = 383) who screened to be at average risk for breast cancer. Women were randomly assigned to the following messaging summaries: annual mammography risks in 40s (Arm 1, n = 124), mammography risks plus family history-based genetic risk (Arm 2, n = 120), and mammography risks, genetic risk, and behavioral alternatives (Arm 3, n = 139). Willingness to delay screening or reduce screening frequency was assessed post-experiment by a set of 5-point Likert scale items. RESULTS: Women in Arm 3 reported significantly greater willingness to delay screening mammography until age 50 (mean = 0.23, SD = 1.26) compared with those in Arm 1 (mean = -0.17, SD = 1.20; p = .04). There were no significant arm differences in willingness to reduce screening frequency. Exposure to the communication messages significantly shifted women's breast cancer-related risk perceptions without increasing unwarranted cancer worry across all three arms. CONCLUSIONS: Providing women with screening information and options may help initiate challenging discussions with providers about potentially low-value screening.

The US Preventive Services Task Force does not recommend routine annual mammography screening for women aged 40­49 at average risk. This study aimed to assess the impact of theory-based persuasive messages on women's willingness to delay mammography screening until age 50 or opt for biennial screenings. In a randomized online experiment, 383 U.S. women aged 40­49 at average risk for breast cancer were assigned to three different message groups. The results showed that women exposed to messaging that included mammography risks, family history-based genetic risk, and behavioral alternatives were significantly more willing to delay screening until age 50. However, there were no significant differences in willingness to reduce screening frequency. The tested communication messages effectively shifted women's breast cancer-related risk perceptions without causing unnecessary worry. Providing women with screening information and options may help initiate challenging discussions with providers about potentially low-value screening.

Avoiding Overtreatment of Women ≥70 With Early-Stage Breast Cancer: A Provider-Level Deimplementation Strategy.

INTRODUCTION: National guidelines recommend against routine axillary staging with sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy (RT) in women ≥70 y with early-stage, hormone receptor-positive, HER2-negative breast cancer and clinically negative axilla; however, these practices remain common. METHODS: We conducted a prospective pilot study from August 2021 to 2022 using an intervention targeting breast surgeons and radiation oncologists in Michigan that aimed to reduce SLNB and RT in eligible patients. The intervention consisted of (1) a geriatric assessment, (2) an assessment of the patient's medical maximizing-minimizing preferences, and (3) a tailored script with counterpoints to reasons patients commonly seek SLNB or RT. At the end of the study period, participants completed a survey providing feedback with the primary outcomes being: acceptability, appropriateness, feasibility, and intention and motivation to use the materials based on validated measures. RESULTS: Participants (n = 23) included 15 breast surgeons and 8 radiation oncologists. Collectively, the materials were used with 115 patients. Considering all materials holistically, acceptability, appropriateness, and feasibility of the intervention were high; participants also intended and were motivated to use the intervention. Scores across all measures were highest for the geriatric assessment and lowest for the tailored script. The major barriers to using the intervention were limited time and instances of disagreement on treatment recommendations among surgeons and radiation oncologists. CONCLUSIONS: The omission of SLNB and adjuvant RT should be discussed in appropriately selected patients. A multifaceted provider-level deimplementation strategy may be an effective means for achieving this goal.

Unmeasured factors are associated with the use of completion lymph node dissection (CLND) in melanoma.

BACKGROUND: Completion lymph node dissection (CLND) was the standard treatment for patients with melanoma with positive sentinel lymph nodes (SLN) until 2017 when data from the DeCOG-SLT and MLST-2 randomized trials challenged the survival benefit of this procedure. We assessed the contribution of patient, tumor and facility factors on the use of CLND in patients with surgically resected Stage III melanoma. METHODS: Using the National Cancer Database, patients who underwent surgical excision and were found to have a positive SLN from 2012 to 2017 were included. A multivariable mixed-effects logistic regression model with a random intercept for the facility was used to determine the effect of patient, tumor, and facility variables on the risk of CLND. Reference effect measures (REMs) were used to compare the contribution of contextual effects (unknown facility variables) versus measured variables on the variation in CLND use. RESULTS: From 2012 to 2017, the overall use of CLND decreased from 59.9% to 26.5% (p < 0.0001). Overall, older patients and patients with government-based insurance were less likely to undergo CLND. Tumor factors associated with a decreased rate of CLND included primary tumor location on the lower limb, decreasing depth, and mitotic rate <1. However, the contribution of contextual effects to the variation in CLND use exceeded that of the measured facility, tumor, time, and patient variables. CONCLUSIONS: There was a decrease in CLND use during the study period. However, there is still high variability in CLND use, mainly driven by unmeasured contextual effects.

Sticking with Programs That Do Not Work: The Role of Escalation of Commitment in Schools.

Schools are the most common site to implement evidence-based prevention programs and practices (EBPs) to improve behavioral and mental health outcomes among children and adolescents. Research has highlighted the critical role of school administrators in the adoption, implementation, and evaluation of such EBPs, focusing on the factors they should consider during the adoption decision and the behaviors needed for successful implementation. However, scholars have only recently begun to focus on the de-adoption or de-implementation of low-value programs and practices to make room for evidence-based alternatives. This study introduces escalation of commitment as a theoretical framework for understanding why school administrators may stick with ineffective programs and practices. Escalation of commitment is a robust decision-making bias in which people feel compelled to continue with a course of action even when performance indicators suggest it is not going well. Using grounded theory methodology, we conducted semi-structured interviews with 24 building- and district-level school administrators in the Midwestern United States. Results suggested that escalation of commitment occurs when administrators attribute the underlying causes of poor program performance not to the program itself but instead to issues related to implementation, leadership, or the limitations of the performance indicators themselves. We also identified a variety of psychological, organizational, and external determinants that accentuate administrators' continuance of ineffective prevention programs. Based on our findings, we highlight several contributions to theory and practice.

Selective de-implementation of routine in vivo dosimetry.

As cone-beam computed tomography (CBCT) has become the localization method for a majority of cases, the indications for diode-based confirmation of accurate patient set-up and treatment are now limited and must be balanced between proper resource allocation and optimizing efficiency without compromising safety. We undertook a de-implementation quality improvement project to discontinue routine diode use in non-intensity modulated radiotherapy (IMRT) cases in favor of tailored selection of scenarios where diodes may be useful. After analysis of safety reports from the last 5 years, literature review, and stakeholder discussions, our safety and quality (SAQ) committee introduced a recommendation to limit diode use to specific scenarios in which in vivo verification may add value to standard quality assurance (QA) processes. To assess changes in patterns of use, we reviewed diode use by clinical indication 4 months prior and after the implementation of the revised policy, which includes use of diodes for: 3D conformal photon fields set up without CBCT; total body irradiation (TBI); electron beams; cardiac devices within 10 cm of the treatment field; and unique scenarios on a case-by-case basis. We identified 4459 prescriptions and 1038 unique instances of diode use across five clinical sites from 5/2021 to 1/2022. After implementation of the revised policy, we observed an overall decrease in diode use from 32% to 13.2%, with a precipitous drop in 3D cases utilizing CBCT (from 23.2% to 4%), while maintaining diode utilization in the 5 selected scenarios including 100% of TBI and electron cases. By identifying specific indications for diode use and creating a user-friendly platform for case selection, we have successfully de-implemented routine diode use in favor of a selective process that identifies cases where the diode is important for patient safety. In doing so, we have streamlined patient care and decreased cost without compromising patient safety.

[Why is it increasingly difficult to "do the right thing" and to "stop doing the wrong thing"? Strategies for reversing low-value practices]. / ¿Por qué resulta cada vez más complicado "hacer lo que hay que hacer" y "dejar de hacer lo que no hay que hacer"? Estrategias para revertir las prácticas de bajo valor.

This manuscript describes the factors that have led to the spread of low-value practices (LVP) and the main initiatives to reverse them. The paper highlights the strategies that have proven to be most useful over the years, from the alignment of clinical practice with "do not do" recommendations, to quaternary prevention and the risks associated with interventionism. Reversing LVP requires a planned process with a multifactorial approach engaging the different actors involved. It considers the barriers to de-implementation of low-value interventions and incorporates tools that facilitate adherence to "do not do" recommendations. Family doctor has an especially relevant role in LVP prevention, detection and de-implementation, due to their coordinating and integrating nature in the patients' healthcare, and because most of the citizens' healthcare demands are managed and resolved at the first level of care.

Physician Perspectives on Reducing Curative Cancer Treatment Intensity for Populations Underrepresented in Clinical Trials.

BACKGROUND: Historically, clinical trials involved adding novel agents to standard of care to improve survival. There has been a shift to an individualized approach with testing less intense treatment, particularly in breast cancer where risk of recurrence is low. Little is known about physician perspectives on delivering less intense treatment for patients who are not well represented in clinical trials. METHODS: Open-ended, individual qualitative interviews with medical oncologists explored their perspectives on trials that test less intense treatment for patients with cancer, with a focus on breast cancer. Interviews were audio-recorded and transcribed. Four independent coders utilized a content analysis approach to analyze transcripts using NVivo. Major themes and exemplary quotes were extracted. RESULTS: Of the 39 participating physicians, 61.5% felt comfortable extrapolating, 30.8% were hesitant, and 7.7% would not feel comfortable extrapolating trial outcomes to underrepresented populations. Facilitators of comfort included the sentiment that "biology is biology" (such that the cancer characteristics were what mattered), the strength of the evidence, inclusion of subset analysis on underrepresented populations, and prior experience making decisions with limited data. Barriers to extrapolation included potential harm over the patient's lifetime, concerns about groups that had minimal participants, application to younger patients, and extending findings to diverse populations. Universally, broader inclusion in trials testing lowering chemotherapy was desired. CONCLUSIONS: The majority (92%) of physicians reported that they would de-implement treatment for patients poorly represented in clinical trials testing less treatment, while expressing concerns about applicability to specific subpopulations. Further work is needed to increase clinical trial representation of diverse populations to safely and effectively optimize treatment for patients with cancer. TRIAL REGISTRATION: NCT03248258.

Facilitators and barriers to reducing chemotherapy for early-stage breast cancer: a qualitative analysis of interviews with patients and patient advocates.

BACKGROUND: As the combination of systemic and targeted chemotherapies is associated with severe adverse side effects and long-term health complications, there is interest in reducing treatment intensity for patients with early-stage breast cancer (EBC). Clinical trials are needed to determine the feasibility of reducing treatment intensity while maintaining 3-year recurrence-free survival of greater than 92%. To recruit participants for these trials, it is important to understand patient perspectives on reducing chemotherapy. METHODS: We collected qualitative interview data from twenty-four patients with Stage II-III breast cancer and sixteen patient advocates. Interviews explored potential barriers and facilitators to participation in trials testing reduced amounts of chemotherapy. As the COVID-19 pandemic struck during data collection, seventeen participants were asked about the potential impact of COVID-19 on their interest in these trials. Interviews were audio-recorded and transcribed, and researchers used qualitative content analysis to code for dominant themes. RESULTS: Seventeen participants (42.5%) expressed interest in participating in a trial of reduced chemotherapy. Barriers to reducing chemotherapy included (1) fear of recurrence and inefficacy, (2) preference for aggressive treatment, (3) disinterest in clinical trials, (4) lack of information about expected outcomes, (5) fear of regret, and (6) having young children. Facilitators included (1) avoiding physical toxicity, (2) understanding the scientific rationale of reducing chemotherapy, (3) confidence in providers, (4) consistent monitoring and the option to increase dosage, (5) fewer financial and logistical challenges, and (6) contributing to scientific knowledge. Of those asked, nearly all participants said they would be more motivated to reduce treatment intensity in the context of COVID-19, primarily to avoid exposure to the virus while receiving treatment. CONCLUSIONS: Among individuals with EBC, there is significant interest in alleviating treatment-related toxicity by reducing chemotherapeutic intensity. Patients will be more apt to participate in trials testing reduced amounts of chemotherapy if these are framed in terms of customizing treatment to the individual patient and added benefit-reduced toxicities, higher quality of life during treatment and lower risk of long-term complications-rather than in terms of taking treatments away or doing less than the standard of care. Doctor-patient rapport and provider support will be crucial in this process.

Using Tailored Messages to Target Overuse of Low-Value Breast Cancer Care in Older Women.

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.

Perceived Barriers to the De-implementation of Routine Preoperative History & Physicals Preceding Low-Risk Ambulatory Procedures: A Qualitative Study of Surgeon Perspectives.

BACKGROUND: For patients undergoing surgery at an Ambulatory Surgical Center, recent changes to Centers for Medicare and Medicaid Services policy allow for the omission of a 30-day preoperative History and Physical (H&P). Preoperative H&Ps for low-risk surgery may contribute to health care waste and lead to unnecessary preoperative testing and treatment cascades. METHODS: In this qualitative study, we conducted 30 semi-structured interviews with surgeons who frequently perform low-risk surgeries. We aimed to evaluate surgeon perspectives on the continued use of the 30-day preoperative H&P and specifically the potential risks and benefits associated with the elimination of a preoperative H&P requirement from institutional practice. We used an interpretive description approach to generate a thematic description. RESULTS: Most participants felt that the 30-day preoperative H&P was low value and frequently described it as "unnecessary," "redundant," or "just checking a box." Many viewed the 30-day requirement as arbitrary and felt that new H&P findings were rare and unlikely to influence surgical care. The participants who favored the preoperative H&P felt it was a safeguard to ensure "nothing was missed" and were less likely to be burdened by the requirement than participants who felt it was low value. CONCLUSIONS: Surgeons performing low-risk procedures question the utility and value of conducting a preoperative H&P within 30 days of surgery. De-implementation of the 30-day preoperative H&P for low-risk patients may increase convenience for patients and providers. Furthermore, it may improve value in surgery by increasing access to services for patients with greater need for preoperative assessment.