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

背景：近一半患有局限性前列腺癌(最常见的非皮肤癌)的退伍军人 美国男性中的恶性肿瘤)接受不适当的、浪费的想象。VHA卓越蓝图 将提高运营效率放在首位。先前寻求限制不适当成像的研究没有评估 这是一种障碍，取得了好坏参半的结果。我们的团队探索了指南不一致的前列腺癌的原因 影像检查发现，1)新诊断的前列腺癌患者很少考虑放射检查。 分期而不是专注于治疗，2)医生信任成像指南，但倾向于遵循自己的直觉， 害怕法医后果，并屈从于经常成像的同事的影响。尽管 在这种不一致的情况下，大多数VHA医生建议或支持大规模的努力来改善成像使用 在威斯康星州。 干预：我们提出了一项多点、阶梯楔形、整群随机试验，以确定 以医生为中心的行为干预在VHA前列腺癌成像中的应用。多层次的干预， 根据理论决定因素框架开发，结合传统医生行为 用新的通信和数据收集方法改变方法。干预措施包括三个方面 组成部分：1)提供给临床医生的审计和反馈系统，告知个别临床医生及其站点 他们的行为与他们的同龄人和公布的指导方针相比如何2)一个学术详细说明的项目 目标是教育提供者有关前列腺癌成像的知识，以及3)CPRS临床订单检查 不恰当的成像。该干预将被引入到10个参与地理分布的研究 网站。 分析计划：我们将在介入前6个月和介入后3个月评估显像率 干预。这项研究的具体目的是试图了解干预对1)设施层面的影响 前列腺癌显像率，2)医生对干预及其治疗的经验和认知 实施，以及3)实施干预和影响成像使用变化的成本。 这些目标将支持后续的干预，以改善VHA的指南一致性成像。 通过这个项目获得的经验将被用来改善与指南一致的护理和增加 其他领域的业务效力。 重要性：本项目旨在描述和分析行为干预的实施情况 改善前列腺癌护理。这种基于理论的干预建立在确定障碍的先前工作的基础上 VHA中符合指南的前列腺癌成像(CDA 11-257)，并在三个水平上解决这些问题： 个人(VHA癌症护理立方体数据的审核和反馈)、设施(学术细节)和系统(CPRS 订单检查)。该团队将评估干预措施的成本影响和提供者的经验，为 优化前列腺癌手术效果的后续大规模VHA实施项目 在VHA上进行成像。当前的应用程序是利用VHA最先进的、集成的 医疗保健提供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，增加对真正需要的人的适当护理，同时节省资金 对于医疗系统来说。

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.