Association for Academic Surgery (AAS)

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Implementation Science: Considerations for an Academic Surgeon

As academic surgeons, we all pride ourselves on our active role in generating, critically appraising, and disseminating evidence; yet this evidence has limited utility until it is adopted into practice. It has been traditionally described that there is a 17-year gap between the generation of new evidence and its incorporation into routine clinical practice.1 Although the research to practice pipeline is improving, there is wide variation in adoption of new findings, with some practices promptly adopted and others never becoming standard practice, despite the existence of compelling evidence. In our own lives, we can probably identify examples of both.

As a surgical oncologist, my field is constantly evolving, and I have enthusiastically adopted paradigm shifting treatment strategies including discontinuation of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel node positive melanoma. Yet, for women over 70 with low-risk breast cancer, I rarely omit sentinel lymph node biopsy despite sufficient evidence that the practice has low value. My behaviors mirror national trends, demonstrating rapid and near-universal discontinuation of CLND for sentinel node positive melanoma and minimal discontinuation of breast sentinel node biopsy in older women with low-risk breast cancer.2,3

The fields of implementation and de-implementation science provide the theory and frameworks to help us understand why we adopt certain evidence-based practices and fail to adopt others. Among the many frameworks, there are typically three key determinants of adoption: the characteristics of the innovation itself, the people who adopt the innovation, and the context into which the innovation arrives. We believe a few have particular relevance in surgery, and specifically for academic surgeons. Integrating these frameworks into our scholarly and clinical work may help improve the research to practice pipeline.

An innovation characteristic that influences adoption is trialability, or the degree to which an innovation can be tried prior to adoption.4 This includes up-front costs (e.g. training, equipment purchases) and an understanding of the potential consequences of failure. As surgeons, we may be hesitant to try a new practice because outcomes are less predictable and failure can result in significant morbidity or even death for our patients. We demand a high degree of certainty that an innovation will be safe or that a good salvage option exists if the new strategy fails.

Working in academic settings, we often have opportunities to conduct and participate in clinical trials, which provide a highly monitored setting and degree of patient “buy-in” to trial new treatment strategies and to observe their effects. This may allow us to feel more comfortable adopting the strategies that are ultimately demonstrated to be effective. Another component of trialability is whether acceptable bailout strategies exist if our initial treatment doesn’t work. One key finding of the studies of discontinuation of CLND for sentinel node positive melanoma was that with adequate surveillance, patients who did have residual nodal disease after sentinel node biopsy that manifested as nodal recurrence during surveillance were almost universally salvaged with surgery.5 This made discontinuation of CLND trialable, and may be one reason why surgeons were comfortable changing their practices.

Considering ourselves early “adopters” of evidence, we in academic surgery are in a unique position. We are often fellowship-trained in narrow subspecialties and may feel that we have achieved mastery of the core operations that comprise the majority of our practices. As a result, we may be slowest to de-implement low value procedures because we perceive that the potential added morbidity of “that extra step” is low in our hands. This may partly explain why there has been limited de-implementation of sentinel node biopsy in older women with low-risk breast cancer and why academic and high volume centers are more likely to perform total thyroidectomy and central neck dissection for small, differentiated thyroid cancer even though guidelines recommend lobectomy alone.6

Finally, our context is distinct. Academic medical centers converge diverse groups of highly specialized clinicians with distinct expertise, creating an environment that facilitates idea sharing. We also have the benefit of trainees who help us constantly question why we do what we do and have the unique benefit of seeing how providers in other specialties practice, becoming “cross-pollinators” of the innovations that exist within our own institutions.

Being in academic surgery affords unique opportunities but also presents distinct barriers to incorporating evidence into practice. We can use implementation and de-implementation frameworks to better understand these factors, to examine our own behaviors, and to bring about needed change in our institutions.

 

References

  1. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011; 104(12):510-520. doi:10.1258/jrsm.2011.110180
  2. Broman KK, Richman J, Bhatia S. Evidence and implementation gaps in management of sentinel node-positive melanoma in the United States. Surgery. Published online February 1, 2022:S0039-6060(21)01248-4. doi:10.1016/j.surg.2021.12.025
  3. Wang T, Bredbeck BC, Sinco B, et al. Variations in Persistent Use of Low-Value Breast Cancer Surgery. JAMA Surg. Published online February 3, 2021. doi:10.1001/jamasurg.2020.6942
  4. Rogers E. Diffusion of Innovations. Fifth. Free Press; 2003.
  5. Broman KK, Hughes T, Dossett L, et al. Active surveillance of patients who have sentinel node positive melanoma: An international, multi-institution evaluation of adoption and early outcomes after the Multicenter Selective Lymphadenectomy Trial II (MSLT-2). Cancer. 2021; 127(13):2251-2261. doi:10.1002/cncr.33483
  6. Montgomery K, Fazendin J, Richman J, Broman KK. Variation in Extent of Surgery for Low Risk Papillary Thyroid Cancer. Presented at Academic Surgical Congress, 2022.
Kristy Broman, MD, MPH

Kristy Broman, MD, MPH

Kristy Broman, MD, MPH is an Assistant Professor in the UAB Division of Surgical Oncology with a clinical practice in skin and soft tissue surgical oncology. She is a graduate of Vanderbilt University School of Medicine in Nashville, Tennessee, where she earned her Medical Degree and Master of Public Health Degree. She then completed residency in General Surgery at Vanderbilt University Medical Center, which included a three-year research fellowship in the Veterans Affairs National Quality Scholar Program, a national training program in conduct of health services research, quality improvement and implementation science. She completed her two-year clinical fellowship training in Surgical Oncology at Moffitt Cancer Center in Tampa, Florida. She is faculty member of the UAB Institute for Cancer Outcomes and Survivorship where she conducts health services and outcomes research, emphasizing implementation strategies for delivery of high-quality care across the cancer care continuum.
Lisa Zubkoff, PhD, MS

Lisa Zubkoff, PhD, MS

Lisa Zubkoff, PhD, MS is an Associate Professor in the Division of Preventive Medicine in the Department of Medicine at the University of Alabama at Birmingham. She also serves as the Associate Director for Research at the Birmingham/Atlanta Geriatric Research Education and Clinical Center (GRECC) at the Birmingham VA Health Care System. Dr. Zubkoff received a Ph.D. and Master of Science from The Dartmouth Institute of Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth. Upon completing her doctoral training, she completed a health services research post-doctoral fellowship at the VA Greater Los Angeles Health Care System, where her training focused on the field of implementation science. Dr. Zubkoff is an implementation scientist and health services researcher. Her research focuses on developing and testing implementation strategies to improve the uptake of evidence-based practices. She has served as PI and Co-Investigator on several studies, including those funded by NIH, VA, and not-for-profits. Her recent work includes the adaptation of quality improvement collaboratives to a virtual learning collaborative as an implementation strategy to foster improvement in healthcare organizations. She is currently PI on an NCI funded study (NCI 1R01CA229197) comparing two strategies to implement an early concurrent palliative care program in community oncology practices (09/2018-02/2024).
Lisa Zubkoff, PhD, MS

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