Implementing Risk-aligned Bladder Cancer Surveillance

实施风险调整的膀胱癌监测

• 批准号: 9719930
• 负责人: Florian R Schroeck
• 金额: --
• 依托单位: WHITE RIVER JUNCTION VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-09-01 至 2023-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9719930
• 关键词: Address; Adoption; Affect; Algorithms; Anxiety; Area; Bladder; Caring; Chronic Disease; Clinical Trials; Cluster randomized trial; Code; Consensus; Cystoscopy; Data; Data Set; Diagnosis; Disease; Effectiveness; Electronic Health Record; Estrogen receptor positive; Family; Feedback; Foundations; Frequencies; Goals; Habits; Healthcare Systems; International; Intervention; Interview; Knowledge; Lead; Leadership; Malignant Neoplasms; Malignant neoplasm of urinary bladder; Maps; Measures; Methods; Monitor; Muscle; Natural Language Processing; Nurses; Operative Surgical Procedures; Outcome; Patient risk; Patients; Patterns of Care; Physicians; Pilot Projects; Procedures; Process; Provider; Recurrence; Research; Risk; Site; Specific qualifier value; Structure; Surveys; Telephone; Testing; Time; Unnecessary Procedures; Veterans; Work; cancer invasiveness; cancer risk; cancer type; care systems; clinical practice; cost; disorder risk; high risk; implementation science; implementation strategy; implementation trial; improved; mortality; recruit

Patients with early stage bladder cancer undergo frequent surveillance cystoscopy procedures where a camera is inserted into the bladder to detect disease recurrence. This makes cystoscopy the most common surgical procedure in the Department of Veterans Affairs (VA) with 30,000 procedures performed annually. There is international consensus that surveillance for early stage bladder cancer should be aligned with each patient’s risk for recurrence and progression. Risk-aligned surveillance entails cystoscopy every year for low- risk early stage bladder cancer and three times a year for high-risk early stage bladder cancer. However, risk-aligned surveillance rarely occurs. In our prior work, we found that 75% of low-risk patients had too much surveillance. Similarly, we found that 31% of high-risk patients had not enough surveillance. Overuse among low-risk patients is undesirable, because unnecessary cystoscopy procedures lead to more discomfort, anxiety, and costs. Underuse among high-risk patients is worrisome, because it puts them at risk for delayed diagnosis of muscle-invasive cancer, which is associated with increased mortality. We also classified VA facilities according to their patterns of care and found that risk-aligned surveillance was rare, with 70 of 85 facilities performing surveillance at a similar frequency for low- and high-risk patients. Little is known about the patient, provider, and facility factors that promote risk-aligned surveillance. Thus, there is a critical need to understand determinants of risk-aligned surveillance and to develop implementation strategies to improve risk- aligned surveillance. Implementing risk-aligned surveillance will spare low-risk patients up to 3 unnecessary procedures per year, while concurrently assuring appropriate surveillance among high-risk patients. Our objective is to develop and pilot test a set of implementation strategies for risk-aligned surveillance. Our rationale is that a set of implementation strategies including 3 to 4 targeted strategies will likely reduce both overuse of surveillance among low-risk and underuse of surveillance among high-risk patients. Guided by the Tailored Implementation for Chronic Diseases (TICD) framework, we will pursue the following Specific Aims: (1) To identify provider- and facility-level barriers and facilitators for risk-aligned bladder cancer surveillance; (2) To develop a set of implementation strategies for risk-aligned bladder cancer surveillance; (3) To pilot a set of implementation strategies to improve risk-aligned bladder cancer surveillance. Our study addresses the HSR&D priority area “Implementation Science”. It is the first to focus on improving care among Veterans diagnosed with bladder cancer, the third most prevalent non-cutaneous cancer in VA, and the first to develop a set of implementation strategies for risk-aligned cancer surveillance. We will use a mixed- methods approach to assess provider- and facility-level barriers and facilitators for risk-aligned surveillance in 4 facilities with greatest room for improvement and in 2 facilities where risk-aligned surveillance is common. We will use a 6-step Intervention Mapping process to map barriers to strategies known to effectively target them. We will involve providers and patients during prioritization and specification of strategies and develop a set of 3 to 4 targeted implementation strategies. Finally, we will conduct a pilot study at the 4 facilities with room for improvement, assessing acceptability, appropriateness, feasibility, and potential effectiveness. After completion of this work, we will have developed a highly specified set of implementation strategies. The next step will be a large scale implementation trial, in which we will test the implementation strategies in a cluster-randomized trial in a wider array of facilities. While this study is focused on bladder cancer, risk-aligned surveillance is also relevant for many other cancers. Thus, the implementation strategies identified herein will be the foundation for efficient risk-aligned cancer surveillance for patients with many types of cancer. As such, our research has the potential for broad impact on delivery of risk-aligned cancer surveillance in VA.

早期膀胱癌的患者经常进行监视膀胱镜检查程序 摄像机被插入膀胱中以检测疾病复发。这使膀胱镜检查成为最常见的 退伍军人事务部（VA）的手术程序每年执行30,000个程序。 有国际共识，应与每种监视进行早期膀胱癌的监视 患者复发和进展的风险。每年与风险一致的监视实体膀胱镜检查 高风险的早期膀胱癌的风险早期膀胱癌和每年三次。 但是，风险一致的监视很少发生。在我们先前的工作中，我们发现75％的低风险患者患有 监视太多。同样，我们发现31％的高危患者的监视不足。过度使用 在低风险患者中，不良患者是不必要的，因为不必要的膀胱镜检查会导致更多的不适感 焦虑和成本。高风险患者的不足是令人惊讶的，因为这会使他们处于延迟的风险 诊断肌肉侵入性癌症，这与死亡率增加有关。我们还将VA分类 设施根据其护理方式，发现风险一致的监视很少见，有70个中有70个 低风险患者的设施以相似的频率进行监视。关于 患者，提供者和设施因素促进风险一致的监视。那是迫切需要的 了解确定风险调整的监视并制定实施策略以改善风险 - 对齐监视。实施风险一致的监视将使低风险患者最多可避免3个不必要的患者 每年的程序，同时确保高危患者的适当监视。 我们的目标是开发和试点测试一套针对风险一致的监视的实施策略。我们的目标是开发和试点测试一套针对风险一致的监视的实施策略。 理由是，包括3至4种目标策略在内的一系列实施策略可能会减少两者 高危患者中低风险和监视不足的监测过度使用。由 针对慢性病（TICD）框架的量身定制实施，我们将追求以下特定目标：（1） 确定提供者和设施级别的障碍和促进者，以进行风险调整的膀胱癌监测； （2）至 制定一套实施策略，以进行风险调整的膀胱癌监测； （3）驾驶一组 实施策略，以改善与风险保持一致的Blader癌症监测。 我们的研究涉及HSR＆D优先领域“实施科学”。这是第一个专注于改进的人 在诊断为膀胱癌的退伍军人中，弗吉尼亚州中第三大普遍的非乳腺癌和 第一个制定一套针对风险一致的癌症监测的实施策略。我们将使用混合 评估提供者和设施级别的障碍和促进者的方法的方法，以进行风险一致的监视 有最大改进空间的设施以及在风险一致性监视的两个设施中很常见的设施。我们 将使用6步干预映射过程将壁垒映射到已知有效针对它们的策略。 我们将在策略的优先级和规格中参与提供者和患者，并开发3组 到4种有针对性的实施策略。最后，我们将在4个设施中进行试点研究， 改进，评估可接受性，适当性，可行性和潜在有效性。 完成这项工作后，我们将制定一套高度指定的实施策略。 下一步将是一项大规模实施试验，我们将在其中测试 在更广泛的设施中，群集随机试验。虽然这项研究的重点是膀胱癌，但风险一致 监视也与许多其他癌症有关。这，本文确定的实施策略将 为许多类型的癌症患者有效地对风险分配的癌症监测的基础。像这样， 我们的研究有可能对VA中风险一致的癌症监测的交付产生广泛的影响。