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

以医生为中心的多模式干预措施，以改善符合指南的前列腺癌成像

• 批准号: 10186493
• 负责人: DANIL V. MAKAROV
• 金额: --
• 依托单位: VA NEW YORK HARBOR HLTHCARE/SYS/BROOKLYN
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-03-01 至 2023-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10186493
• 关键词: Academic Detailing; Address; Affect; Agreement; Behavior; Behavior Therapy; Caring; Clinical; Cluster randomized trial; Communication Methods; Data; Data Collection; Diagnostic radiologic examination; Effectiveness; Feedback; Fright; Geographic Locations; Geography; Goals; Guidelines; Healthcare Systems; Image; Individual; Integrated Delivery of Health Care; Intervention; Interview; Intuition; Knowledge; Legal; Malignant Neoplasms; Malignant neoplasm of prostate; Medical; Medical Care Costs; Methods; Newly Diagnosed; Newly Diagnosed Disease; Operative Surgical Procedures; PSA screening; Patients; Perception; Physicians; Population; Preparation; Provider; Publishing; Reporting; Research; Residencies; Resources; Risk; Savings; Self Efficacy; Site; Societies; Staging; Structure; Surgeon; System; Time; Training; Trust; Variant; Veterans; Work; academic program; base; behavior change; cancer care; cancer imaging; clinical research site; cost; design; effectiveness evaluation; evidence base; experience; health care delivery; high risk men; implementation cost; improved; intervention cost; intervention effect; medical specialties; men; multimodality; novel; peer; prostate cancer risk; provider behavior; theories

Background: Almost half of Veterans with localized prostate cancer (the most common non-cutaneous malignancy among US men) receive inappropriate, wasteful imaging. The VHA Blueprint for Excellence prioritizes increasing operational effectiveness. Prior studies seeking to limit inappropriate imaging did not assess barriers and achieved mixed results. Our team has explored the causes of guideline-discordant 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) physician trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from colleagues who image frequently. In spite of such discrepant v iews, most VHA physicians suggested or supported a large-scale effort to improve imaging use across VHA. Intervention: We propose a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on VHA prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Determinants Framework, 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 inappropriate imaging. The intervention will be introduced to 10 participating geographically-distributed study sites. Analysis Plan: We will assess imaging rates 6 months prior to the intervention and 3 months following the intervention. The study’s specific aims seek to understand the effects of the intervention on 1) facility-level prostate cancer imaging rates, 2) physician experience with and perceptions of the intervention and its implementation, and 3) the costs of both implementing the intervention and affecting change in imaging use. These aims will support a subsequent intervention to improve guideline-concordant imaging across VHA. Experience gained through this project will be leveraged to improve guideline-concordant care and increase operational effectiveness in other domains. Importance: This project seeks to describe and analyze the implementation of a behavioral intervention to improve prostate cancer care. This theory-based intervention builds on prior work identifying barriers to guideline-concordant prostate cancer imaging in VHA (CDA 11-257) and addresses these at three levels: individual (audit and feedback with VHA Cancer Care Cube data), facility (academic detailing) and system (CPRS Order Check). The team will assess the intervention’s cost impact and providers’ experiences in preparation for a subsequent large -scale VHA implementation project optimizing the operational effectiveness of prostate cancer imaging across VHA. The current application is an opportunity to leverage VHA’s state-of-the-art, integrated healthcare delivery system to implement a carefully designed, theory-based behavioral intervention to reduce harmful, inappropriate care, increase appropriate care to those who truly need it, and simultaneously save money for the healthcare system.

背景：几乎一半的退伍军人患有局限性前列腺癌（最常见的非皮肤癌） 美国男性恶性肿瘤）接受了不适当、浪费的成像。 先前寻求限制不当成像的研究并未评估优先事项。 我们的团队探索了与指南不一致的前列腺癌的原因。 影像学检查发现 1) 新诊断的前列腺癌患者很少关心放射线照相 分期，而是专注于治疗，2) 医生信任影像指南，倾向于遵循自己的直觉， 担心医疗法律后果，并屈服于经常出现的同事的影响。 鉴于这种不同的观点，大多数 VHA 医生建议或支持大规模努力改善影像学的使用 穿过VHA。 干预：我们提出了一项多中心、阶梯式楔形、整群随机试验，以确定干预措施的效果 以医生为中心的 VHA 前列腺癌成像使用的行为干预 多层次干预， 根据理论决定因素框架开发，结合​​传统医生行为 采用新颖的沟通和数据收集方法来改变方法。干预措施包括三个部分。 组成部分： 1) 一个审核和反馈系统，用于向个别长者及其场所通报有关情况 他们的行为与同龄人以及已发布的指南相比如何 2) 一个学术细节计划 目标是对提供者进行有关前列腺癌成像的教育，以及 3) 进行 CPRS 临床指令检查以了解潜在的情况 不适当的成像将被引入到 10 项参与的地理分布研究中。 网站。 分析计划：我们将评估干预前 6 个月和干预后 3 个月的成像率 该研究的具体目标是了解干预措施对 1) 设施层面的影响。 前列腺癌成像率，2) 医生对干预措施及其看法的经验 实施，以及 3) 实施干预措施和影响成像使用变化的成本。 这些目标将支持后续干预，以指导改善整个 VHA 的线一致性成像。 通过该项目获得的经验将用于改善符合指南的护理并增加 其他领域的运营效率。 重要性：该项目旨在描述和分析行为干预的实施，以 这种基于理论的前列腺干预措施建立在之前识别障碍的工作的基础上。 VHA (CDA 11-257) 中符合指南的前列腺癌成像并在三个层面上解决这些问题： 个人（使用 VHA Cancer Care Cube 数据进行审核和反馈）、设施（学术细节）和系统（CPRS 订单检查）。团队将评估干预措施的成本影响和提供商的经验，以准备进行。 随后大规模VHA项目的实施优化了前列腺癌的运营效率 当前的应用程序是利用 VHA 最先进的集成技术的机会。 医疗保健服务系统实施精心设计的、基于理论的行为干预，以减少 有害的、不适当的护理，为真正需要的人增加适当的护理，同时节省金钱 对于医疗保健系统。