De-Implementation of Low-Value Cervical Cancer Screening

点击翻译按钮获取中文摘要

Modified Project Summary/Abstract Section PROJECT SUMMARY Up to 45% of all cervical cancer screening in the United States is considered to be overuse, despite consensus guidelines and strong evidence of the limited benefit and potential harm of low-value screening. Overscreening for cervical cancer includes screening more frequently than is recommended or outside the recommended age groups. Overscreening can lead to increased false positives and psychosocial harms, cause unnecessary treatment of cervical abnormalities that would likely resolve on their own, and result in excess financial and opportunity costs. While there are several implementation strategies shown to be effective for increasing cervical cancer screening, it is largely unknown how best to decrease overscreening in routine care. As such, there is a critical need to develop effective strategies for ensuring de-implementation of outdated screening practices. To help fill this gap, this study will 1) test the independent and combined effects of patient- and clinician-directed de-implementation strategies on rates of cervical cancer overscreening in comparison to usual care, and 2) evaluate contextual mechanisms contributing to the success or failure of each de-implementation strategy using coincidence analysis. To achieve these aims, a 2x2 randomized controlled trial with approximately 200 clinicians and 2,400 patients will be conducted in primary care and gynecology clinics affiliated with a large healthcare system with high rates of cervical cancer overscreening. The highly efficient factorial and pragmatic design will enable assessment of independent and combined effects of each strategy. Drawing from systematic evidence of the effectiveness of nudge strategies to increase guideline adherence and an integrated theoretical model, the specific de-implementation strategies to be tested are: 1) theory-based messaging shown to be effective at decreasing overscreening intentions (patient nudge strategy); and 2) point of care reminders alerting clinicians if patients are not due for screening (clinician nudge strategy). The primary de-implementation outcome is reduction in the rate of cervical cancer overscreening among females who are not due for screening based on evidence-based guidelines. Secondary de-implementation outcomes, including reach, acceptability, and feasibility, and implementation costs, and clinical outcomes including rate of abnormal results, false-positives, and diagnostic procedures will also be measured. Following the trial, a stratified, embedded cohort of patients and clinicians will be surveyed and interviewed to evaluate contextual factors contributing to the success or failure of each strategy using coincidence analysis. This innovative project responds directly to the call by the National Cancer Institute to develop and test de-implementation strategies in cancer control. Further, the proposed low-touch strategies are designed to support widespread and equitable implementation across diverse settings, and, if successful, be translated to address other forms of overuse across primary and specialty care. This work will also help to broadly advance causal theory in de-implementation science by evaluating underlying contextual mechanisms that contribute to the effectiveness of strategies among diverse populations.