Designing a theory-based intervention to improve the guideline-concordant use of imaging to stage incident prostate cancer

Clinical Effect of Fuzheng Guben Decoction in the Treatment of Localized Prostate Cancer and Its Influence on Immune Function under Continuous Nursing Intervention

In order to explore the clinical effect and immune function of patients with localized prostate cancer combined with continuous nursing intervention and Fuzheng Guben decoction, a total of 72 patients with prostate cancer admitted to our hospital from January 2020 to June 2021 are selected and analyzed. The patients are randomly divided into a study group and control group randomly, and the control group and the research group are treated with routine intervention and chemotherapy, continuous nursing intervention, and Fuzheng Guben decoction on the basis of chemotherapy, respectively. The incidence of postoperative urinary incontinence and other complications between the two groups are counted, and the differences of FHIT, CatD, CatL, CD68, and CD83 levels in the patients are compared. Furthermore, the total treatment response rate and self-attitude score of the two groups are compared after treatment. The experimental results demonstrate that the total effective rate and self-attitude score of patients in the study group are significantly better than those in the control group.

De-implementing low-value care in cancer care delivery: a systematic review

BACKGROUND

Accumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings.

METHODS

We systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus from 1 January 1990 to 4 March 2021. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies' key characteristics including design, type of cancer, outcome(s), objective(s), de-implementation interventions description, and determinants of the de-implementation interventions. To extract the data, pairs of authors placed text from included articles into the appropriate cells within our framework. We analyzed extracted data from each cell to describe the studies and findings of de-implementation interventions aiming to reduce low-value cancer care.

RESULTS

Out of 2794 studies, 12 met our inclusion criteria. The studies covered several cancer types, including prostate cancer (n = 5), gastrointestinal cancer (n = 3), lung cancer (n = 2), breast cancer (n = 2), and hematologic cancers (n = 1). Most of the interventions (n = 10) were multifaceted. Auditing and providing feedback, having a clinical champion, educating clinicians through developing and disseminating new guidelines, and developing a decision support tool are the common components of the de-implementation interventions. Six of the de-implementation interventions were effective in reducing low-value care, five studies reported mixed results, and one study showed no difference across intervention arms. Eleven studies aimed to de-implement low-value care by changing providers' behavior, and 1 de-implementation intervention focused on changing the patients' behavior. Three studies had little risk of bias, five had moderate, and four had a high risk of bias.

CONCLUSIONS

This review demonstrated a paucity of evidence in many areas of the de-implementation of low-value care including lack of studies in active de-implementation (i.e., healthcare organizations initiating de-implementation interventions purposefully aimed at reducing low-value care).

Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging

BACKGROUND

Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that (1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment and (2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer.

METHODS

We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: (1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers' and to published guidelines, (2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and (3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically distributed study sites.

DISCUSSION

This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed.

TRIAL REGISTRATION

CliniclTrials.gov NCT03445559. Prospectively registered on February 26, 2018.

The cost, survival, and quality-of-life implications of guideline-discordant imaging for prostate cancer

Background

National Comprehensive Cancer Network (NCCN) guidelines for incident prostate cancer staging imaging have been widely circulated and accepted as best practice since 1996. Despite these clear guidelines, wasteful and potentially harmful inappropriate imaging of men with prostate cancer remains prevalent.

Aim

To understand changing population‐level patterns of imaging among men with incident prostate cancer, we created a state‐transition microsimulation model based on existing literature and incident prostate cancer cases.

Methods

To create a cohort of patients, we identified incident prostate cancer cases from 2004 to 2009 that were diagnosed in men ages 65 and older from SEER. A microsimulation model allowed us to explore how this cohort's survival, quality of life, and Medicare costs would be impacted by making imaging consistent with guidelines. We conducted a probabilistic analysis as well as one‐way sensitivity analysis.

Results

When only imaging high‐risk men compared to the status quo, we found that the population rate of imaging dropped from 53 to 38% and average per‐person spending on imaging dropped from $236 to $157. The discounted and undiscounted incremental cost‐effectiveness ratios indicated that ideal upfront imaging reduced costs and slightly improved health outcomes compared with current practice patterns, that is, guideline‐concordant imaging was less costly and slightly more effective.

Conclusion

This study demonstrates the potential reduction in cost through the correction of inappropriate imaging practices. These findings highlight an opportunity within the healthcare system to reduce unnecessary costs and overtreatment through guideline adherence.

A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study

OBJECTIVE

To understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer.

METHODS

We implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. RESULTS FIFTY SEVEN PERCENT: (117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care.

CONCLUSION

While the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.

To call or not to call: behavioral determinants influencing the decision of intensivists to consult poison centers for calcium channel blocker poisoning

Purpose: This study aimed to define the behavioral determinants influencing the decision of intensivists to consult a poison center (PC) when managing patients with calcium channel blocker (CCB) poisoning.Material and methods: Semi-structured interviews were conducted involving a convenience sample of 18 intensivists. Two independent reviewers analyzed the interview responses using the Theoretical Domains Framework. Based on the impact and frequency of the reported behaviors, we selected the most relevant domains likely to influence intensivists' decision to consult a PC for CCB poisoning.Results: Beliefs influencing physicians positively to consult a PC for CCB poisoning were identified in the following domains: knowledge (e.g., lower level of evidence), social or professional role and identity (e.g., high credibility attributed to the PC), reinforcement (e.g., multiple drug poisoning, infrequent or potentially lethal poisoning, medicolegal considerations), and behavioral regulation (e.g., facilitated access of PC to patient's hospital chart, direct communication with a toxicologist). Beliefs deterring physicians from consulting a PC for CCB poisoning were identified in the following domains: knowledge (e.g., better awareness of recommendations decreases tendency to call), goals (e.g., priority for patient stabilization), and memory, attention, and decision process (e.g., cognitive overload due to an unstable patient).Conclusion: This qualitative study identified potential behavioral targets that future implementation strategies should address to improve collaboration between PCs and intensivists. In light of our results, the Québec PC now asks clinicians if the poisoned patient is unstable prior to collecting any other information. When necessary, a teleconference with the toxicologist is proposed earlier than before.

Science in the Heartland: Exploring determinants of offering cancer clinical trials in rural-serving community urology practices

OBJECTIVE

Engaging community urologists in referring patients to clinical trials could increase the reach of cancer trials and, ultimately, alleviate cancer disparities. We sought to identify determinants of referring patients to clinical trials among urology practices serving rural communities.

METHODS

We conducted semistructured qualitative interviews based on the Theoretical Domains Framework at nonmetropolitan urology practices located in communities offering urological cancer trials. Participants were asked to consider barriers and strategies that might support engaging their patients in discussions about urological cancer clinical trials and referring them appropriately. Recorded interviews were transcribed and coded using template analysis.

RESULTS

Most participants were not aware of available trials and had no experience with trial referral. Overall, participants held positive attitudes toward clinical trials and recognized their potential roles in accrual, but limited local resources reduced opportunities for offering trials. Most participants expressed a need for increased human, financial, and other resources to support this role. Many participants requested information and training to increase their knowledge of clinical trials and confidence in offering them to patients. Participants highlighted the need to build efficient pathways to identify available trials, match eligible patients, and facilitate communication and collaboration with cancer centers for patient follow-up and continuity of care.

CONCLUSIONS

With adequate logistical and informational support, community urology practices could play an important role in clinical trial accrual, advancing cancer research and increasing treatment options for rural cancer patients. Future studies should explore the effectiveness of strategies to optimize urology practices' role in clinical trial accrual.

Barriers and Facilitators of Intensivists' Adherence to Hyperinsulinemia-Euglycemia Therapy in the Treatment of Calcium Channel Blocker Poisoning

INTRODUCTION

Adherence to poison center (PC) recommendations for the management of calcium channel blocker (CCB) poisoning is inconsistent. This study aimed to identify behaviors that determine adherence to hyperinsulinemia-euglycemia therapy (HIET) for CCB poisoning.

METHODS

Semistructured interviews were conducted involving a convenience sample of 18 intensivists. Interview responses were analyzed using the theoretical domains framework (TDF) to identify relevant domains influencing physician adherence to HIET. Two independent reviewers performed qualitative content analysis of the interview transcripts to identify beliefs influencing decisions to initiate HIET. Initially, beliefs were classified and frequencies reported as being likely to facilitate, likely to decrease, or unlikely to affect adherence. Subsequently, beliefs were linked to a domain within the TDF. Based on the potential impact on physician behavior and frequency of reported behavior, we selected the most relevant domains likely to influence physician adherence to HIET for CCB poisoning.

RESULTS

Positive beliefs were identified in the following domains: "behavioral regulation" (e.g., algorithm for adjustment of perfusions), "belief about capabilities" (e.g., confidence about being able to manage HIET), "belief about consequences" (e.g., fear of clinical deterioration), and "reinforcement" (e.g., clinical instability). Negative beliefs were identified in the following domains as "nature of behavior" (e.g., preference for vasopressors over HIET) and "environmental context and resources" (e.g., accessing dextrose 50% and increased nurse workload).

CONCLUSION

This qualitative study identified potential behavioral targets for future implementation strategies to address to improve adherence to HIET.