With Wynne Norton, PhD, Program Director in the Division of Cancer Control & Population Sciences at NCI
By Sarah DiGiulio
Health care providers across all disciplines are struggling to provide better care and cut costs. And in oncology, the issue is becoming ever more prescient. New drugs are more effective, but more expensive to make. Better tests and screens are available, but may not be worthwhile for everyone. And the consequences of not delivering sustainable, high-quality cancer care are life-threatening.
That's why Wynne Norton, PhD, Program Director in the Division of Cancer Control and Population Sciences at the NIH, along with her NCI colleagues, wrote a Comments and Controversies article in a recent issue of the Journal of Clinical Oncology outlining a better strategy for studying and de-implementing overuse in cancer care (2018; doi:10.1200/JCO.18.00589).
There are two bottom-line messages from the article, Norton shared with Oncology Times. "First, we wanted to encourage researchers and practitioners to develop and test approaches for effectively de-implementing various cancer-focused practices.
"Second, to support this type of work, we tried to highlight some of the key factors that are likely to play a role in this process, and therefore are likely targets of change needed to facilitate de-implementation," she said.
Norton and her coauthors recognize that de-implementation—especially when you're talking about doing it in cancer care where the stakes are so high—is a "difficult enterprise," they noted in the article. But it's also critical to helping cancer care evolve and improve.
Here's why Norton said establishing a process to accomplish it matters.
1. Why did you and your colleagues decide to write this article now?
"Over the past several years, there has been increasing attention to the issue of overuse of ineffective, low-value, harmful, and unproven practices, interventions, and treatments in the scientific literature—and among professional societies, funding agencies, and research-based organizations.
"Of course, this is a very important issue to patients, providers, and payers, as it cuts across many health conditions, delivery settings, and patient populations.
"We've been involved in several efforts recently to better understand the issue of overuse (e.g., review and summary of grants funded by the NIH on this topic; presentations at the Preventing Overdiagnosis Conference), and to begin to identify ways in which we may either prevent or de-implement the use of these types of practices. Recent high-profile studies in cancer—the TAILORx trial in particular—signaled a timely opportunity for us to summarize issues related to de-implementation.
"Ultimately, we wanted to encourage the research and practice communities to move beyond describing the problem of overuse toward developing and testing ways to de-implement ineffective, low-value, harmful, and unproven practices in cancer care delivery. The overarching goal is to achieve the optimal balance of implementation of beneficial interventions along with de-implementation of harmful or low-value interventions."
2. How would you define what a "de-implementation framework" is and how you came up with this one?
"The de-implementation framework is a conceptualization of multi-level factors that are likely to influence and impact the de-implementation process. We wanted to propose a way of thinking about de-implementation that would simultaneously guide providers, clinic managers, and quality improvement specialists in their practice-based efforts and help researchers identify and test strategies to facilitate de-implementation. We hope it serves as a blueprint for advancing the science and practice of de-implementation.
"[To develop it], first we reviewed the research and practice landscape on overuse, medical reversals, inappropriate use, and low-value care, including seminal work by Drs. Carrie Colla, Deborah Korenstein, Daniel Morgan, Daniel Niven, and Vinay Prasad (among others), prominent campaigns (e.g., Choosing Wisely), and various organizations and agencies (e.g., National Academy of Medicine, Canadian Deprescribing Network).
"[My co-authors] and I had many conversations about these issues and solicited feedback from our colleagues at various conferences and meetings. Along the way, we developed, edited, and refined the de-implementation framework until we had the final version, which is now published in Journal of Clinical Oncology.
"Although we are happy with the framework in its current version, we anticipate that it will need to be revised over time as practice experience and scientific evidence accumulate. We look forward to seeing how others may contribute to this work."
3. What's next and how do you envision cancer care providers and the cancer care community using this framework?
"For providers, clinic managers, quality improvement specialists, and other key players involved in cancer care delivery, we hope this framework will provide an outline for how to identify, prioritize, and facilitate de-implementation.
"For researchers, we hope that the framework highlights many of the key factors that are likely to facilitate or impede the de-implementation process, and leverage this information to develop and test strategies to effectively drive de-implementation (where appropriate) in cancer care delivery settings."