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

背景：几乎一半的退伍军人患有局限性前列腺癌（最常见的非皮肤性前列腺癌）， 美国男性中的恶性肿瘤）接受不适当的、浪费的成像。VHA卓越蓝图 优先考虑提高业务效率。先前的研究试图限制不适当的成像，但没有评估 障碍，取得了好坏参半的结果。我们的团队已经探索了指南不一致前列腺癌的原因 结果发现：1）新诊断的前列腺癌患者很少关注放射学检查 分期，而不是专注于治疗，2）医生相信成像指南，但倾向于遵循自己的直觉， 害怕医学法律后果，并屈服于经常成像的同事的影响。尽管 由于这些不一致的观点，大多数VHA医生建议或支持大规模努力改善成像的使用 在VHA。 干预：我们建议进行一项多中心、阶梯楔形、随机分组试验，以确定 以医生为中心的VHA前列腺癌成像使用行为干预。多层次的干预， 根据理论决定因素框架，结合传统的医生行为， 用新的通信和数据收集方法改变方法。干预措施包括三个 组成部分：1）审计和临床医生反馈系统，告知个体临床医生及其研究中心 他们的行为如何与同龄人和已公布的指导方针进行比较2）一个学术计划， 教育提供者有关前列腺癌成像的目标，以及3）CPRS临床订单检查， 不适当的成像。将在10项参与的地理分布研究中引入干预措施 网站. 分析计划：我们将评估介入前6个月和介入后3个月的成像率。 干预该研究的具体目标是了解干预措施对1）设施水平的影响， 前列腺癌成像率，2）医生对干预的经验和看法， 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干预，以改善VHA的指南一致性成像。 通过该项目获得的经验将被用来改善指南一致性护理， 其他领域的业务效率。 重要性：该项目旨在描述和分析行为干预的实施， 改善前列腺癌护理。这种基于理论的干预建立在以前的工作， VHA中的指南一致性前列腺癌成像（CDA 11-257），并在三个层面解决这些问题： 个人（使用VHA Cancer Care Cube数据进行审核和反馈）、机构（学术细节）和系统（CPRS 订单检查）。该小组将评估干预措施的成本影响和提供者的经验， 随后的大规模VHA实施项目优化了前列腺癌的操作效果 跨VHA进行成像。目前的应用程序是一个机会，利用VHA的最先进的，集成的 医疗保健提供系统，以实施精心设计的，基于理论的行为干预，以减少 有害的，不适当的护理，增加对那些真正需要的人的适当护理，同时节省资金 for the healthcare健康system系统.

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.