De-implementation of Mammography Overuse in Older Racially and Ethnically Diverse Women

项目总结 在执行科学(IS)中，取消执行被认为是一个关键但研究不足的领域。 需要进行研究以确定识别、选择和裁剪的最佳方法和途径 取消执行战略。取消对老年人进行常规癌症筛查，例如 乳房X光检查为乳腺癌的筛查提供了极好的机会，既促进了乳腺癌的科学发展，也为乳腺癌的诊断提供了新的途径。 实施和改善老年人的护理提供和健康结果。而国家指导方针则是 不支持对老年妇女进行常规乳房X光检查，并建议考虑疾病、生活 预期和患者的知情偏好，~56%的≥75岁女性报告接受了乳房X光检查， 其中包括50%的预期寿命为10年的女性。我们的初步研究确定了多层次的障碍 和促进者，以减少组织中老年妇女过度使用乳房X光检查(例如 系统警报、患者提醒函)、提供者/诊所(例如，知识、临床规范)和患者(例如，习惯， 知识)级别。在知识到行动模型的启发下，我们提出了一项研究，以消除 老年妇女过度使用乳房X光检查(即减少或停止乳房X光检查) 在一个庞大的医疗保健系统中，妇女为纽约市不同种族的人口提供服务。在……里面 目标1，我们将在患者、提供者和组织中确定一系列取消实施策略 减少≥75岁女性过度使用乳房X光检查的水平。我们将使用众包的方式， 成功应用于新兴的参与式信息系统方法(创新锦标赛)，以生成快速数据 从不同的利益相关者(80-100名患者/家庭成员，80-100名提供者/管理人员)收集 社区和多个医疗保健系统)关于影响取消执行的因素。将这一点结合起来 凭借我们丰富的定性初步数据，以及来自双过程理论的原理，我们将制定出独特的 目标2中的取消执行战略。在目标2中，我们将确定取消执行的优先顺序并为其量身定制 患者、提供者/诊所和组织层面的战略。我们将招聘12-15名专家来确定优先顺序 基于可行性和可接受性的战略，并提出关键属性(例如，持续时间、频率、内容) 对于每种策略，并采用离散选择实验来引出患者(n=75-100)和提供者(n=75-100) 每个优先策略的可修改属性的首选项。在目标3中，我们将评估可行性， 可接受性，以及在试点整群随机试验(8个诊所)中使用量身定制的取消实施战略。 使用顺序混合方法设计，我们将评估策略的使用、停用结果(例如 减少乳房X光检查的过度使用)，以及患者、提供者和 组织层级。数据将确定可行性，并为战略的有效性提供初步数据 将在未来的混合2试验中进行测试，并为推进取消实施框架和 选择非执行战略以减少使用低价值护理的方法。

PROJECT SUMMARY De-implementation is recognized as a critical but understudied area within implementation science (IS). Research is needed to determine the optimal methods and approaches for identifying, selecting, and tailoring de-implementation strategies. De-implementation of routine cancer screening in older adults, such as mammography screening for breast cancer, offers excellent opportunities for both advancing the science of de- implementation and improving care delivery and health outcomes in older adults. While national guidelines do not support routine mammography in older women and recommend consideration of morbidities, life expectancy and patients’ informed preferences, ~56% of women ≥75 years report receiving mammography, including 50% of women with life expectancy <10 years. Our preliminary research identified multi-level barriers and facilitators to de-implementation of mammography overuse among older women at the organizational (e.g. system alerts, patient reminder letters), provider/clinic (e.g., knowledge, clinic norms), and patient (e.g. habit, knowledge) levels. Informed by the Knowledge-to-Action Model, we propose a study for de-implementation of mammography overuse in older women (i.e., reducing the frequency or cessation of mammography) in older women across a large healthcare system serving a racially/ethnically diverse population in New York City. In Aim 1, we will identify a range of de-implementation strategies at the patient, provider, and organizational levels for reducing mammography overuse in women ages ≥75 years. We will use a crowdsourcing method, successfully applied in an emerging participatory IS approach (innovation tournament) to generate rapid data collection from diverse stakeholders (80-100 patients/family members, 80-100 providers/administrators from the community and multiple healthcare systems) on factors that influence de-implementation. Combining this data with our rich qualitative preliminary data, and principles from Dual Process Theory, we will develop distinct de-implementation strategies for refinement in Aim 2. In Aim 2, we will prioritize and tailor de-implementation strategies at patient, provider/clinic, and organizational levels. We will recruit 12-15 experts to prioritize strategies based on feasibility and acceptability, and propose key attributes (e.g., duration, frequency, content) for each strategy, and employ discrete choice experiment to elicit patient (n=75-100) and provider (n=75-100) preferences for modifiable attributes of each prioritized strategy. In Aim 3, we will evaluate the feasibility, acceptability, and use of the tailored de-implementation strategies in a pilot cluster randomized trial (8 clinics). Using a sequential mixed-methods design, we will assess use of strategies, de-adoption outcomes (e.g. reduction of mammography overuse), and theoretical mechanisms of strategies at the patient, provider, and organizational levels. Data will establish feasibility and provide preliminary data for effectiveness of strategies to be tested in future Hybrid 2 trial, and lay the groundwork for advancing de-implementation frameworks and methodological approaches for selecting de-implementation strategies to reduce the use of low-value care.