A Statewide Intervention to Reduce Use of Unproven or Ineffective Breast Cancer Care

Challenged by public opinion, peers and the Congressional Budget Office, a number of
specialty societies have recently begun to develop "Top Five" lists of relatively expensive
procedures that do not provide meaningful benefit to at least some categories of patients for
whom they are commonly ordered. The Choosing Wisely® campaign is the most visible example.
The extent to which the development of these lists has influenced the behavior of physicians
or patients, however, remains unknown.

In this study, investigators partner with the Wisconsin Collaborative for Healthcare Quality
(WCHQ), a statewide consortium of hospitals, medical practices and health systems, to examine
the effectiveness of two organizational interventions in reducing unproven or ineffective
breast cancer care. Two interventions will be tested: (a) A "basic" public reporting
intervention which summarizes on a public website practice-level statistics regarding use of
targeted ineffective or unproven interventions for breast cancer and (ii) an "enhanced"
intervention, augmenting public reporting with a smart phone-based application (App) that
gives providers just-in-time information, decision-making tools, and personalized patient
education materials that support reductions in the use of breast cancer interventions
targeted based upon Choosing Wisely® or national oncology society guidelines. Specifically,
the aims are: (1) To examine whether basic public reporting reduces use of targeted breast
cancer practices among a contemporary cohort of patients with incident breast cancer in the
intervention state relative to usual care in comparison states, using Marketscan and Medicare
claims data while adjusting for possible confounders and temporal trends; (2) To examine the
effectiveness of the enhanced intervention relative to the basic intervention; and (3) To
simulate cost savings forthcoming from nationwide implementation of both interventions
(relative to each other and to usual care) and to describe the implications of these findings
for reimbursement policy and program initiatives.

The results will provide rigorous evidence regarding the effectiveness of a unique all-payer,
all-age public reporting system for influencing provider behavior that may be easily
exportable to other states. Findings will be further relevant to the ACO environment, which
is expected to provide financial disincentives for providing ineffective or unproven care.

Inclusion Criteria:

I. Health care providers: Health care providers (regardless of age, gender or
race/ethnicity) in participating WCHQ practices who will provide breast cancer care to
about 9,000 women who had an incident breast cancer surgery between 2014-2017.

II. Patients: Medicare and Marketscan women who had an incident breast cancer surgery
between 2014-2017. No exclusions will be made by age or race/ethnicity. The focus on women
is dictated by the very low prevalence of breast cancer among men.

Identification of incident breast cancer surgery in these datasets will be done using a
validated algorithm developed by Nattinger et al.

Exclusion Criteria:

- Male patients are excluded from this analysis due to the low prevalence of breast
cancer among males.