De-implementation of low value castration for men with prostate cancer

项目背景：前列腺癌是男性首位的癌症。患有前列腺癌的男性中有三分之一是 在某个时间点用长效注射药物化学阉割(例如，雄激素剥夺疗法或 ADT)。这每年影响数以千计的男性的福祉。尽管一些患者在以下方面受益 存活和症状改善时，通常也会使用ADT进行化学去势 对患者的健康益处很小，甚至没有，这引发了低价值护理的问题。越来越多的人意识到 阉割的危害(例如，心脏病发作、骨质疏松症、性功能丧失)造成了对患者安全的担忧。 尽管如此，ADT在低价值病例中的使用仍然存在，例如用于局限性前列腺癌的治疗。 前列腺癌患者体外ADT化学去势等无效有害做法 证据基础的一部分是解除执行的理想目标。取消实施，或停止低值 这种做法有可能改善患者的预后，降低医疗成本。但是，提供商 关于取消实施的首选项没有得到很好的理解，可能会取消实施 干预的范围从直截了当的公式化限制政策到共同决策。两种干预措施 在临床实践中，需要根据提供者的意见为可接受性和可行性量身定做策略，包括 在试飞之前进行试飞。由于许多医疗实践缺乏证据并造成伤害，强大的，行为的 将提供者偏好纳入取消执行战略制定的基于理论的方法 将推进实施研究和实践。 项目目标：本研究将使用以理论为基础的混合方法来确定、定制和试点 两种不同的取消实施战略，在交付、影响和预期结果方面存在很大差异 减少低价值ADT的使用，为随机比较有效性试验做准备。 项目方法：这个创新的混合方法研究项目有三个目标。目标1：评估 前列腺癌化学去势的偏好和障碍。在指导下 理论领域框架，来自设施的泌尿科医生具有最高的去势率 将与综合交付系统进行面谈，以确定以下方面的关键首选项和取消实施障碍 减少去势作为前列腺癌的治疗。这项定性工作将在收集RICH的同时告知目标2 关于两个拟议的试点干预战略的信息。目标2：使用离散选择实验，一个 新的障碍优先排序方法，用于取消实施战略定制。全国泌尿科医生调查 将优先考虑目标1中确定的停止去势作为前列腺癌局部治疗的关键障碍 采用离散选择实验设计。这些量化结果将确定最重要的 为准备实现目标3，需要通过调整两个试点取消执行战略来克服障碍 领航。目标3：试验两个量身定制的去实施策略，以减少去势为局限性的前列腺 癌症治疗。在目标1和目标2调查结果的基础上，将试行两项取消执行战略。 一种策略将侧重于组织层面的处方限制，另一种策略将侧重于医生/患者 决策。结果将包括可接受性、可行性和可扩展性，以准备 比较这两种差异很大的去执行策略的有效性试验。这是一项创新 制定去执行战略的方法将改变去势的方式和原因 通过结合提供者偏好和策略定制，为局部性前列腺癌提供支持。这项工作将 促进低价值癌症护理的去实施科学，并促进参与随后的去实施 实施评估试验，通过试点定制解决偏好和关切。

Project Background: Prostate cancer is the leading male cancer. One in three men with prostate cancer is chemically castrated at some point with long-acting injectable drugs (i.e., androgen deprivation therapy or ADT). This impacts the well-being of thousands of men annually. Although some patients benefit in terms of survival and symptom improvement, chemical castration with ADT is also commonly performed when there are little to no health benefits to patients raising questions of low value care. A growing awareness of castration harms (e.g., heart attack, osteoporosis, loss of sexual function) creates patient safety concerns. Despite this, ADT use in low value cases, such as for localized prostate cancer treatment persists. Ineffective and harmful practices such as chemical castration of prostate cancer patients with ADT outside of the evidence base are ideal targets for de-implementation. De-implementation, or stopping low value practices, has the potential to improve patient outcomes and decrease healthcare costs. However, provider preferences regarding de-implementation are not well understood, and possible de-implementation interventions range from blunt formulary restriction policies to shared decision-making. Both intervention strategies need tailoring based on provider input for acceptability and feasibility in clinical practice, including piloting prior to trialing. As many medical practices lack evidence and cause harm, robust, behavioral theory-based methods for incorporating provider preferences into deimplementation strategy development will advance both implementation research and practice. Project Objectives: This study will use a theory-based, mixed methods approach to identify, tailor and pilot two different de-implementation strategies that vary widely in delivery, impact, and expected results for reducing low value ADT use, in preparation for a randomized comparative effectiveness trial. Project Methods: This innovative mixed-methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the Theoretical Domains Framework, urologists from facilities with the highest castration rates across an integrated delivery system will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment, a novel barrier prioritization approach, for de-implementation strategy tailoring. A national survey of urologists will prioritize key barriers identified in Aim 1 for stopping castration as localized prostate cancer treatment using a discrete choice experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient decision-making. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies. This innovative approach to de-implementation strategy development will transform how and why castration is performed for localized prostate cancer through combining provider preferences and strategy tailoring. This work will advance de-implementation science for low value cancer care and foster participation in a subsequent de- implementation evaluation trial by addressing preferences and concerns through pilot tailoring.