De-implementation of inappropriate thyroid ultrasound

PROJECT SUMMARY/ABSTRACT Inappropriate use of thyroid ultrasound (iTUS) is an important driver of thyroid cancer overdiagnosis and overtreatment, which involves high-risk procedures and long-term therapeutics that cause medical, psychosocial, and financial hardships for patients. Cumulative annual cost of well-differentiated thyroid cancer care in the U.S. has been estimated to exceed $1.5 billion and is projected to reach $3.5 billion by 2030, and the potential cost after 5 years of thyroid cancer diagnosis is $50,000 per patient. Thyroid cancer is one of the fastest-growing cancers in the U.S, but mortality remains very low. Approximately 25% of new cases are attributable to the identification of small thyroid cancers that are unlikely to cause harm if they were left undiagnosed and untreated. The biggest driver of small thyroid cancer diagnosis is iTUS use in asymptomatic people, a practice discouraged by clinical guidelines. The pervasiveness of iTUS despite recommendations against it suggests the need for active strategies to eliminate it. The process of eliminating practices that are not evidence-based is known as de-implementation. To date, no studies have provided a replicable and useful way for health systems to identify their iTUS practices, and there has been no systematic evaluation of multilevel factors driving it, such that we lack key information about targeted, acceptable, and feasible de- implementation strategies. Without them, overuse will persist. To fill this gap, we will leverage a multidisciplinary team with vast experience in computer phenotyping expertise, machine learning, and mixed method research. We will also use two unique databases: the Rochester Epidemiology Project, a medical record-linkage system that captures health care information from the entire population of 27 counties in Minnesota and Wisconsin, and the Patient-Centered Clinical Research Network (PCORnet) that shares a common data model to organize data into a standard structure. There are three aims. Aim 1: Using the REP and two PCORnet sites, to develop a replicable computer phenotype to identify patients receiving iTUS. Aim 2: Using 4 PCORnet sities, to identify patient, clinician, and practice factors associated with iTUS in a representative sample of healthcare practices. Aim 3: Using mixed methods, to understand factors and identify potential strategies for iTUS de-implementation acceptable to the patient, clinician, and health system stakeholders. This proposal is responsive to the objectives of NOT-CA-20-021 to explore de-implementation of ineffective or low-value clinical practices along the cancer care continuum. At the end of this study, we will have developed and validated a computer phenotype to identify iTUS across diverse settings, as well as a list of acceptable strategies likely to decrease iTUS. These findings will be broadly disseminable and will pave the way for studies—deployed in diverse health systems and targeting patients, clincians, and organizations—that test the effectiveness of the de-implementation strategies identified here.