Variations in Persistent Use of Low-Value Breast Cancer Surgery

Abstract

IMPORTANCEThrough the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation and have identified patient-level and clinician-level determinants of continued overuse. However, little information exists about facility-level variation or determinants of differential deimplementation.OBJECTIVE To identify variation and determinants of persistent use of low-value breast cancer surgical care.DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study in which reliability-adjusted facility rates of each procedure were calculated using random-intercept hierarchical logistic regression before and after evidence demonstrated that each procedure was unnecessary. The National Cancer Database is a prospective cancer registry of patients encompassing approximately 70% of all new cancer diagnoses from more than 1500 facilities in the United States. Data were analyzed from November 2019 to August 2020. The registry included women 18 years and older diagnosed as having breast cancer between 2004 and 2016 and meeting inclusion criteria for each Choosing Wisely recommendation.MAIN OUTCOMES AND MEASURES Rate of each low-value breast cancer procedure based on facility type and breast cancer volume categories before and after the release of data supporting each procedure's omission. RESULTSThe total cohort included 920 256 women with a median age of 63 years. Overall, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. Most women in this cohort were insured (51% private and 47% public), were living in a metropolitan or urban area (88% and 11%, respectively), and originated from the top half of income-earning households (65.5%). While there was significant deimplementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines supporting omission of these procedures, rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased during the study period. Academic research programs and high-volume facilities overall demonstrated the greatest reduction in use of these low-value procedures. There was significant interfacility variation for each low-value procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy rates ranged from 25% to 97%. Pearson correlation coefficient for each combination of 2 of the 4 procedures was less than 0.11, suggesting that hospitals were not consistent in their deimplementation performance across all 4 procedures. Many were high outliers in one procedure but low outliers in another.CONCLUSIONS AND RELEVANCE Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and perfor...

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“…Our provider-level findings could underlie, at least in part, the differential de-implementation of four low-value breast cancer services selected by the Choosing Wisely campaign. For instance, significant de-implementation of axillary lymph node dissection and lumpectomy re-excision compared with stable to increasing rates of contralateral prophylactic mastectomy and sentinel lymph node dissection [ 30 ]. The former two also being at the tail end of de-implementation.…”

De-implementing Low-Value Care in Cancer Care Delivery: A Systematic Review

“…However, none of the included studies measured the collective-level factors (e.g., community, organizational characteristics, and reimbursement policies) that were associated with the de-implementation of low-value care. This is an important gap because, in addition to individual-level factors, many collective-level factors (e.g., organizational culture, leadership, resources, and nancial status) contribute to the utilization of low-value care [40,41]. In many cases, healthcare organizations intentionally decide to continue providing low-value care.…”

De-escalation in breast cancer surgery

“…After dissemination of the trial results at national meetings in 2010 and in a landmark publication in 2011, ALND was substantially de-escalated in appropriate populations within 18 months. Specifically, the rates of ALND use in patients with minimal nodal disease decreased from 63% in 2004 to 14% in 2016, with the most substantial decrease occurring between 2010 and 2011, corresponding to the release of the Z0011 results 7 . This decrease in the rate of ALND use was noted across care environments and in several countries 8 – 10 .…”

“…In contrast to these successful deimplementation efforts, some breast surgical practices designated as low value remain common despite national recommendations supporting their omission. These include contralateral prophylactic mastectomy (CPM) in women with average-risk unilateral breast cancer and SLNB in women aged >70 years with HR + , HER2-negative early-stage breast cancer 7 . Similar to ALND for minimal nodal disease and re-excision for close but negative surgical margins, these practices expose patients to harms and costs without providing a survival benefit, which has resulted in national recommendation to avoid their use.…”