Optimizing Imaging Use Among Veterans with Prostate Cancer

描述(由申请人提供)： 候选人：Danil Makarov博士是一名泌尿科医生，也是一名受过奖学金培训的卫生服务研究员。他计划通过这个职业发展奖，在健康服务研究方法和行为干预方面获得更多的专业知识。候选人将与他的主要导师，一位医生行为干预专家，以及其他决策科学、大数据集分析和定性方法专家合作。掌握这些方法将使应聘者成为一名独立的退伍军人管理局调查员，能够识别医疗实践和提供中的低效率，并设计和实施优化医疗保健提供的战略。背景：在前列腺癌(美国男性中最常见的非皮肤恶性肿瘤)的初步评估中，患者接受指南一致性成像的机会可能更多地取决于他所在的地区，而不是他的疾病特征。临床医生使用成像的倾向可能会因地区而异，比如恒温器的设置，在大多数患者接受扫描的某些区域调高，在很少扫描的其他区域调低。这表明，只关注减少不适当成像的政策可能只是通过降低恒温器来采取行动，可能会冒着减少适当成像的风险。为了 为了设计和实施优化前列腺癌成像的政策，重要的是要了解前列腺癌成像的区域差异以及恒温器模型对其影响的程度。项目：建议的研究项目的目标是了解前列腺癌成像的区域差异的范围、原因和影响。在具体目标#1中，候选人将在两个新的数据集中测试恒温器模型，该数据集中包括来自退伍军人事务部癌症登记中心和SEER-Medicare的患者，代表具有不同支付模式、系统结构和资格标准的系统。为了进一步了解成像差异的潜在原因，该项目将探索不同传输系统的区域性前列腺癌显像率(特定目标2)，并将使用半结构化访谈(特定目标3)进一步深入和详细地了解这些数据，以确定医生和患者对成像的态度。为了确定区域成像差异的影响，候选人将构建一个决策分析模型(特定目标#4)，评估各种成像策略在成本和疾病检测方面的权衡。这些基于模型的策略将与目前的护理进行比较，以确定新策略可能带来的益处的大小。候选人将学习和利用定性和定量(混合方法)方法来解决这个问题，因为这两种方法都不能孤立地充分做到这一点。他还将学习决策分析建模和行为干预，这是将有效实践转化为大型医疗系统所必需的技能。候选人计划将获得的数据和研究经验作为IIR应用程序的基础，以开发和试点决策辅助和行为干预，以优化前列腺癌退伍军人的成像使用。 公共卫生相关性： 这项拟议的研究项目的目标是了解退伍军人前列腺癌成像的区域差异的范围、原因和影响。候选人将学习和利用定性和定量(混合方法)方法以及决策分析来解决这一问题。该提案将有助于提高为患有前列腺癌的退伍军人提供的医疗保健质量，并允许候选人发展成为退伍军人管理局的独立调查员，专注于与癌症相关的健康服务研究。

DESCRIPTION (provided by applicant): Candidate: Dr. Danil Makarov is a urologist and a fellowship-trained health services researcher. He plans, through this career development award, to gain additional expertise in health services research methodology and behavioral intervention. The candidate will collaborate with his primary mentor, an expert in physician behavioral intervention, as well as others expert in decision science, analysis of large datasets and qualitative methods. Mastery of these methodologies will allow the candidate to become an independent VA investigator, able to identify inefficiencies in medical practice and delivery as well as to design and implement strategies optimizing the delivery of medical care. Background: In the initial evaluation of prostate cancer (the most-commonly diagnosed non-cutaneous malignancy among US men), a patient's chances of receiving guideline-concordant imaging may be more dependent on the region in which he lives than on his disease characteristics. The propensity for clinicians to use imaging may vary across regions like settings on a thermostat, dialed up high in some areas where most patients receive scans and dialed down low in other areas where few are scanned. This suggests that policies focusing solely on reducing inappropriate imaging might simply act by dialing the thermostat down, potentially risking a reduction in appropriate imaging. In order to design and implement policies to optimize prostate cancer imaging, it is important to understand regional variation in prostate cancer imaging and the extent to which the thermostat model contributes to it. Project: The goals of the proposed research project are to understand the scope, the causes and the effects of regional variation in prostate cancer imaging. In Specific Aim #1, the candidate will test the thermostat model in two new datasets comprising patients from the VA Central Cancer Registry and SEER- Medicare, representing systems with different payment models, system structures, and eligibility criteria. To understand further the potential causes of imaging variation the project will explore regional prostate cancer imaging rates across delivery systems (Specific Aim #2) and will contribute further depth and detail to these data using semi-structured interviews (Specific Aim #3) to determine physicians' and patients' attitudes regarding imaging. To determine the effects of regional imaging variation, the candidate will construct a decision analytic model (Specific Aim #4) assessing the tradeoffs in cost and disease detection of various imaging strategies. These model-based strategies will be compared to current care in order to determine the magnitude of possible benefit which a new strategy might deliver. The candidate will learn and utilize both qualitative and quantitative (mixed-methods) methodologies to address this question, as neither method could adequately do so in isolation. He will also learn decision analytic modeling and behavioral intervention, skils essential for the translation of effective practices into large healthcare systems. The candidate plans to use the acquired data and research experience as a foundation for an IIR application to develop and pilot a decision aid and behavioral intervention to optimize imaging use among veterans with incident prostate cancer. PUBLIC HEALTH RELEVANCE: The goals of the proposed research project are to understand the scope, the causes and the effects of regional variation in prostate cancer imaging amongveterans. The candidate will learn and utilize both qualitative and quantitative (mixed-methods) methodologies as well as decision analysis to address this problem. The proposal will serve to improve the quality of healthcare delivered to veterans with prostate cancer and allow the candidate to develop into an independent investigator in the VA focused on cancer-related health services research.