Optimizing Imaging Use Among Veterans with Prostate Cancer

描述（由申请人提供）： 候选人：丹尼尔·马卡洛夫 (Danil Makarov) 博士是一名泌尿科医生和接受过专科培训的卫生服务研究员。他计划通过这个职业发展奖获得卫生服务研究方法和行为干预方面的更多专业知识。候选人将与其主要导师（医生行为干预专家）以及决策科学、大型数据集分析和定性方法方面的其他专家合作。掌握这些方法将使候选人成为一名独立的 VA 调查员，能够识别医疗实践和服务中的低效率，并设计和实施优化医疗服务提供的策略。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，患者接受符合指南的影像学检查的机会可能更多地取决于他所居住的地区，而不是他的疾病特征。临床医生使用成像的倾向可能因地区而异，例如恒温器的设置，在大多数患者接受扫描的某些区域调高，在很少接受扫描的其他区域调低。这表明，仅仅专注于减少不适当成像的政策可能只是通过调低恒温器来发挥作用，从而可能面临减少适当成像的风险。为了 设计和实施优化前列腺癌成像的政策时，了解前列腺癌成像的区域差异以及恒温器模型对其贡献的程度非常重要。项目：拟议研究项目的目标是了解前列腺癌成像区域变异的范围、原因和影响。在具体目标 #1 中，候选人将在两个新数据集中测试恒温器模型，其中包括来自 VA 中心癌症登记处和 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变异的潜在原因，该项目将探索跨传输系统的区域前列腺癌成像率（具体目标#2），并将使用半结构化访谈（具体目标#3）为这些数据提供进一步的深度和细节，以确定医生和患者对成像的态度。为了确定区域成像变化的影响，考生将构建一个决策分析模型（具体目标#4），评估各种成像策略的成本和疾病检测的权衡。这些基于模型的策略将与当前的护理进行比较，以确定新策略可能带来的潜在效益的大小。候选人将学习并利用定性和定量（混合方法）方法来解决这个问题，因为这两种方法都无法单独充分地做到这一点。他还将学习决策分析建模和行为干预，这些技能是将有效实践转化为大型医疗保健系统所必需的技能。该候选人计划利用获得的数据和研究经验作为 IIR 应用程序的基础，开发和试点决策辅助和行为干预，以优化患有前列腺癌的退伍军人的成像使用。 公共卫生相关性： 拟议研究项目的目标是了解退伍军人前列腺癌成像区域差异的范围、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个问题。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，并使候选人能够发展成为退伍军人管理局的一名独立调查员，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.