Implementing Risk-aligned Bladder Cancer Surveillance

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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.