Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging

Abstract Background Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that (1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment and (2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer. Methods We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: (1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers’ and to published guidelines, (2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and (3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically distributed study sites. Discussion This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed. Trial registration CliniclTrials.gov NCT03445559. Prospectively registered on February 26, 2018

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Protocol: A Multi-Modal, Physician-Centered Intervention to Improve Guideline-Concordant Prostate Cancer Imaging

10.21203/rs.3.rs-28497/v1 ◽

2020 ◽

Author(s):

Danil V Makarov ◽

Shannon Ciprut ◽

Matthew Kelly ◽

Dawn Walter ◽

Michele G Shedlin ◽

...

Keyword(s):

Prostate Cancer ◽

Data Collection ◽

Behavior Change ◽

Cancer Imaging ◽

Intervention Strategy ◽

Theoretical Domains Framework ◽

Audit And Feedback ◽

Veterans Health ◽

Health Administration ◽

Multi Level

Abstract Background: Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that 1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment, 2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer.Methods: We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: 1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers’ and to published guidelines 2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and 3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically-distributed study sites.Discussion: This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed.Trial Registration: This study was prospectively registered on February 26, 2018, CliniclTrials.gov: NCT03445559 (2a)

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Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging

10.21203/rs.3.rs-25383/v1 ◽

2020 ◽

Author(s):

Danil V Makarov ◽

Shannon Ciprut ◽

Matthew Kelly ◽

Dawn Walter ◽

Michele G Shedlin ◽

...

Keyword(s):

Prostate Cancer ◽

Data Collection ◽

Behavior Change ◽

Cancer Imaging ◽

Intervention Strategy ◽

Theoretical Domains Framework ◽

Audit And Feedback ◽

Veterans Health ◽

Health Administration ◽

Multi Level

Abstract Background Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that 1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment, 2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer. Methods We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: 1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers’ and to published guidelines 2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and 3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically-distributed study sites. Discussion This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed.

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Learning from the “tail end” of de-implementation: the case of chemical castration for localized prostate cancer

Implementation Science Communications ◽

10.1186/s43058-021-00224-8 ◽

2021 ◽

Vol 2 (1) ◽

Author(s):

Ted A. Skolarus ◽

Jane Forman ◽

Jordan B. Sparks ◽

Tabitha Metreger ◽

Sarah T. Hawley ◽

...

Keyword(s):

Prostate Cancer ◽

Cancer Treatment ◽

Theoretical Domains Framework ◽

Localized Prostate Cancer ◽

Strategy Development ◽

Veterans Health ◽

Health Administration ◽

Prostate Cancer Treatment ◽

Chemical Castration ◽

Provider Perspectives

Abstract Background Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel’s Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development. Methods We used national cancer registry and administrative data from 2016 to 2017 to examine the variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high- and low-performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B model to generate a conceptual framework for addressing low-value ADT practices. Results Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment, including barriers and facilitators to de-implementing low-value ADT. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe 2); willing, under some circumstances, to prescribe: and 3) prescribe as an acceptable treatment option. Provider capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social roles and influences regarding ADT practices, such as prior training. Provider motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence, and beliefs about the consequences of prescribing or not prescribing ADT. Conclusions Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer. Trial registration ClinicalTrials.gov, NCT03579680

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Learning From the 'Tail End' of De-implementation: The Case of Chemical Castration for Localized Prostate Cancer

10.21203/rs.3.rs-132359/v1 ◽

2020 ◽

Author(s):

Ted A. Skolarus ◽

Jane Forman ◽

Jordan B. Sparks ◽

Tabitha Metreger ◽

Sarah T. Hawley ◽

...

Keyword(s):

Prostate Cancer ◽

Cancer Treatment ◽

Theoretical Domains Framework ◽

Localized Prostate Cancer ◽

Strategy Development ◽

Veterans Health ◽

Health Administration ◽

Prostate Cancer Treatment ◽

Chemical Castration ◽

Provider Perspectives

Abstract Background: Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel’s Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development.Methods: We used national cancer registry and administrative data from 2016-2017 to examine variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high and low performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B Model to generate a conceptual framework for addressing low-value ADT practices.Results: Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe, 2) willing, under some circumstances, to prescribe, and 3) prescribe as an acceptable treatment option. Provider Capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider Opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social influences regarding ADT practices, such as prior training. Provider Motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence and beliefs about the consequences of prescribing or not prescribing ADT. Conclusions: Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer.

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Bone modifying agents in veterans with castration-resistant prostate cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.6582 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 6582-6582

Author(s):

Jordan Bauman ◽

Kyle Kumbier ◽

Jennifer A. Burns ◽

Jordan Sparks ◽

Phoebe A. Tsao ◽

...

Keyword(s):

Prostate Cancer ◽

Zoledronic Acid ◽

Bone Metastases ◽

Specific Antigen ◽

Veterans Health ◽

Health Administration ◽

Castration Resistant Prostate Cancer ◽

National Guidelines ◽

Castration Resistant ◽

Unit Increase

6582 Background: Skeletal related events (SREs) are a known complication for the 80% of men with metastatic prostate cancer who have bone metastases. Previous studies have demonstrated that bone modifying agents (BMAs) such as zoledronic acid and denosumab reduce SREs in men with metastatic castration-resistant prostate cancer who have bone metastases and are now recommended by national guidelines. We sought to investigate factors associated with use of BMAs in Veterans with CRPC across the Veterans Health Administration (VA). Methods: Using the VA Corporate Data Warehouse, consisting of aggregated medical record data from 130 facilities, we used an algorithm previously published to identify men with a diagnosis of castration-resistant prostate cancer (CRPC) based on rising prostate specific antigen (PSA) levels while on androgen deprivation therapy and who received systemic treatment for CRPC with one of the commonly used therapies: abiraterone, enzalutamide, docetaxel, ketoconazole between 2010 and 2017. To account for clustering among facilities, we used a multilevel multivariable logistic regression to determine the association of patient and disease-specific variables on the odds of a patient receiving a BMA after they started treatment for CRPC. Results: Of 4,998 patients with CRPC in our cohort, 2223 (44%) received either zoledronic acid or denosumab at some point after they were initiated on treatment for CRPC. After adjusting for other variables and accounting for a facility, the odds of receiving a BMA decreased by 3% for every additional year of age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.96-0.98), and decreased significantly with increasing comorbid conditions (OR 0.94, 95% CI 0.72-0.98 for Charlson Comorbidity Index [CCI] of 1; OR 0.69, 95% CI 0.59-0.81 for CCI 2+). Patients who were Black had 25% lower odds of receiving a BMA than patients who were White (OR 0.75, 95% CI 0.65-0.87). PSA at time of CRPC treatment start had a small but not significant effect on receipt of a BMA (OR 1.04, 95% CI 1.00-1.08) for every unit increase of PSA on the log scale. PSA doubling time was not associated with receipt of a BMA. The presence of a diagnosis code for bone metastases was far lower than expected in this cohort of patients with CRPC (40.7%), and thus was not included in the model. We did not expect the presence of bone metastases to vary significantly among the other independent variables. Conclusions: Despite most patients with CRPC historically having bone metastases, less than half of patients with CRPC received a BMA. Patients who are older, had more comorbidities, or were Black were less likely to receive a BMA after starting treatment for CRPC. Understanding factors that lead to different patterns of treatment can guide initiatives toward more guideline-concordant care.

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Increasing enrolment in a national VA transitions of care programme: a pre–post evaluation of a data dashboard and nudge-based intervention

BMJ Health & Care Informatics ◽

10.1136/bmjhci-2021-100416 ◽

2021 ◽

Vol 28 (1) ◽

pp. e100416

Author(s):

Brigid Connelly ◽

Chelsea Leonard ◽

David Gaskin ◽

Theodore Warsavage ◽

Heather Gilmartin

Keyword(s):

Performance Metrics ◽

Transitions Of Care ◽

Audit And Feedback ◽

Veterans Health ◽

Health Administration ◽

Care Programme ◽

Post Evaluation ◽

The Difference ◽

Two Phases ◽

One Year

BackgroundThe rural transitions nurse programme (TNP) is a care coordination intervention for high-risk veterans. An interactive dashboard was used to provide real-time performance metrics to sites as an audit and feedback tool. One-year post implementation, enrolment goals were not met. Nudge emails were introduced to increase TNP veteran enrolment. This study evaluated whether veteran enrolment increased when feedback occurred through a dashboard plus weekly nudge email versus dashboard alone.Setting/populationThis observational study included veterans who were hospitalised and discharged from four Veterans Health Administration hospitals participating in TNP.MethodsVeteran enrolment counts between the dashboard phase and dashboard plus weekly nudge email phase were compared. Nudge emails included run charts of enrolment data. The difference of means for weekly enrolment between the two phases were calculated. After 3 months of nudge emails, a survey assessing TNP transitions nurse and physician champion perceptions of the nudge emails was distributed.ResultsThe average enrolment for the four TNP sites during the ~20-month dashboard only phase was 4.23 veterans/week. The average during the 3-month dashboard plus nudge email phase was 4.21 veterans/week. The difference in means was −0.03 (p=0.73). Adjusting for time trends had no further effect. Four nurses responded to the survey. Two nurses reported neutral and two reported positive perceptions of the nudge emails.ConclusionDrawing attention to metrics, through nudge emails, maintained, but did not increase TNP veteran discharges compared to dashboard feedback alone.

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Practice patterns in metastatic castration-resistant prostate cancer (mCRPC): Evidence from the veterans health administration

Annals of Oncology ◽

10.1093/annonc/mdx370.021 ◽

2017 ◽

Vol 28 ◽

pp. v277-v278 ◽

Cited By ~ 1

Author(s):

A. Halwani ◽

Z. Burningham ◽

K.M. Rasmussen ◽

V. Patil ◽

S. Narayanan ◽

...

Keyword(s):

Prostate Cancer ◽

Practice Patterns ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Castration Resistant Prostate Cancer ◽

Castration Resistant

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Results of a Regional Effort to Improve Warfarin Management

Annals of Pharmacotherapy ◽

10.1177/1060028016681030 ◽

2016 ◽

Vol 51 (5) ◽

pp. 373-379 ◽

Cited By ~ 6

Author(s):

Adam J. Rose ◽

Angela Park ◽

Christopher Gillespie ◽

Carol Van Deusen Lukas ◽

Al Ozonoff ◽

...

Keyword(s):

Quality Improvement ◽

New England ◽

Audit And Feedback ◽

Quality Improvement Initiative ◽

Veterans Health ◽

Health Administration ◽

Process Of Care ◽

Processes Of Care ◽

Anticoagulation Control

Background: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. Objective: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). Methods: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. Results: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. Conclusions: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

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The LEAP Program: Quality Improvement Training to Address Team Readiness Gaps Identified by Implementation Science Findings

Journal of General Internal Medicine ◽

10.1007/s11606-020-06133-1 ◽

2020 ◽

Author(s):

Laura J. Damschroder ◽

Nicholas R. Yankey ◽

Claire H. Robinson ◽

Michelle B. Freitag ◽

Jennifer A. Burns ◽

...

Keyword(s):

Quality Improvement ◽

Training Program ◽

Learning Community ◽

Organizational Readiness ◽

Audit And Feedback ◽

Veterans Health ◽

Health Administration ◽

Program Satisfaction ◽

Implementing Change ◽

Assignment Completion

Abstract Background Integrating evidence-based innovations (EBIs) into sustained use is challenging; most implementations in health systems fail. Increasing frontline teams’ quality improvement (QI) capability may increase the implementation readiness and success of EBI implementation. Objectives Develop a QI training program (“Learn. Engage. Act. Process.” (LEAP)) and evaluate its impact on frontline obesity treatment teams to improve treatment delivered within the Veterans Health Administration (VHA). Design This was a pre-post evaluation of the LEAP program. MOVE! coordinators (N = 68) were invited to participate in LEAP; 24 were randomly assigned to four starting times. MOVE! coordinators formed teams to work on improvement aims. Pre-post surveys assessed team organizational readiness for implementing change and self-rated QI skills. Program satisfaction, assignment completion, and aim achievement were also evaluated. Participants VHA facility-based MOVE! teams. Interventions LEAP is a 21-week QI training program. Core components include audit and feedback reports, structured curriculum, coaching and learning community, and online platform. Main Measures Organizational readiness for implementing change (ORIC); self-rated QI skills before and after LEAP; assignment completion and aim achievement; program satisfaction. Key Results Seventeen of 24 randomized teams participated in LEAP. Participants' self-ratings across six categories of QI skills increased after completing LEAP (p< 0.0001). The ORIC measure showed no statistically significant change overall; the change efficacy subscale marginally improved (p < 0.08), and the change commitment subscale remained the same (p = 0.66). Depending on the assignment, 35 to 100% of teams completed the assignment. Nine teams achieved their aim. Most team members were satisfied or very satisfied (81–89%) with the LEAP components, 74% intended to continue using QI methods, and 81% planned to continue improvement work. Conclusions LEAP is scalable and does not require travel or time away from clinical responsibilities. While QI skills improved among participating teams and most completed the work, they struggled to do so amid competing clinical priorities.

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