Implementing Risk-aligned Bladder Cancer Surveillance

早期膀胱癌患者经常接受监视膀胱镜检查，其中 摄像头被插入膀胱中，以检测疾病的复发。这使得膀胱镜检查成为最常见的 退伍军人事务部(VA)的外科手术，每年进行30,000例手术。 国际上已达成共识，对早期膀胱癌的监测应与 患者复发和进展的风险。风险对准的监测需要每年对低风险患者进行膀胱镜检查 风险早期膀胱癌，一年三次为高危早期膀胱癌。 然而，风险导向的监测很少发生。在我们之前的工作中，我们发现75%的低风险患者患有 监视太多了。同样，我们发现31%的高危患者没有得到足够的监测。过度使用 在低风险患者中是不可取的，因为不必要的膀胱镜检查程序会导致更多的不适， 焦虑和成本。在高危患者中使用不足令人担忧，因为这会使他们面临延迟的风险 肌肉浸润性癌症的诊断，这与死亡率增加有关。我们还将退伍军人管理局 根据他们的护理模式对设施进行监测，并发现风险导向监测很少见，85人中有70人 以类似频率对低风险和高风险患者进行监测的设施。人们对此知之甚少 促进风险一致性监测的患者、提供者和设施因素。因此，迫切需要 了解风险协调监控的决定因素，并制定实施战略以改善风险- 对齐监视。实施风险对齐的监测将使低风险患者节省多达3个不必要的费用 每年进行手术，同时确保在高危患者中进行适当的监测。 我们的目标是制定和试行一套风险协调监测的实施战略。我们的 理由是，一套包括3到4个有针对性的战略的实施战略可能会减少这两种情况 在低危患者中过度使用监测，在高危患者中监测不足。在指导下 针对慢性病的具体实施框架，我们将追求以下具体目标：(1) 为风险导向的膀胱癌监测确定提供者和设施层面的障碍和促进者；(2) 制定一套以风险为导向的膀胱癌监测实施策略；(3)试行一套 实施战略，改进风险导向的膀胱癌监测。 我们的研究涉及高铁与研发的优先领域“实施科学”。它是第一个专注于改进的公司 诊断为膀胱癌的退伍军人的护理，膀胱癌是退伍军人退伍军人中第三大最常见的非皮肤癌 第一个为风险对齐的癌症监测制定一套实施战略。我们将使用混合的- 评估提供者和设施级别的障碍和促进者的方法方法，以进行4年的风险协调监测 有最大改进空间的设施和2个经常进行风险对齐监测的设施。我们 将使用一个6步干预映射过程，将障碍映射到已知的有效针对它们的策略。 我们将让提供者和患者参与策略的优先排序和规范，并制定一套3 至4个有针对性的实施战略。最后，我们将在4个设施进行试验性研究，并提供空间 改进，评估可接受性、适当性、可行性和潜在有效性。 在这项工作完成后，我们将制定一套高度具体的实施战略。这个 下一步将是大规模的实施试验，我们将在 在更广泛的设施中进行的整群随机试验。虽然这项研究的重点是膀胱癌，但风险对齐 监测也与许多其他癌症有关。因此，本文确定的实施战略将 成为对多种癌症患者进行有效的风险对齐癌症监测的基础。因此， 我们的研究有可能对退伍军人管理局的风险导向癌症监测的实施产生广泛影响。

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.