Unpacking overuse of androgen deprivation therapy for prostate cancer to inform de-implementation strategies

BACKGROUND

Many men with prostate cancer will be exposed to androgen deprivation therapy (ADT). While evidence-based ADT use is common, ADT is also used in cases with no or limited evidence resulting in more harm than benefit, i.e., overuse. Since there are risks of ADT (e.g., diabetes, osteoporosis), it is important to understand the behaviors facilitating overuse to inform de-implementation strategies. For these reasons, we conducted a theory-informed survey study, including a discrete choice experiment (DCE), to better understand ADT overuse and provider preferences for mitigating overuse.

METHODS

Our survey used the Action, Actor, Context, Target, Time (AACTT) framework, the Theoretical Domains Framework (TDF), the Capability, Opportunity, Motivation-Behavior (COM-B) Model, and a DCE to elicit provider de-implementation strategy preferences. We surveyed the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on the likelihood of stopping overuse as ADT monotherapy for localized prostate cancer ("yes"/"probably yes," "probably no"/"no"), and characterized corresponding Likert scale responses to seven COM-B statements. We used multivariable regression to identify associations between stopping ADT overuse and COM-B responses.

RESULTS

Our survey was completed by 84 respondents (13% response rate), with 27% indicating "probably no"/"no" to stopping ADT overuse. We found differences across respondents who said they would and would not stop ADT overuse in demographics and COM-B statements. Our model identified 2 COM-B domains (Opportunity-Social, Motivation-Reflective) significantly associated with a lower likelihood of stopping ADT overuse. Our DCE demonstrated in-person communication, multidisciplinary review, and medical record documentation may be effective in reducing ADT overuse.

CONCLUSIONS

Our study used a behavioral theory-informed survey, including a DCE, to identify behaviors and context underpinning ADT overuse. Specifying behaviors supporting and gathering provider preferences in addressing ADT overuse requires a stepwise, stakeholder-engaged approach to support evidence-based cancer care. From this work, we are pursuing targeted improvement strategies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03579680.

Behavioural Sciences Contribution to Suppressing Transmission of Covid-19 in the UK: A Systematic Literature Review

BACKGROUND

Governments have relied on their citizens to adhere to a variety of transmission-reducing behaviours (TRBs) to suppress the Covid-19 pandemic. Understanding the psychological and sociodemographic predictors of adherence to TRBs will be heavily influenced by the particular theories used by researchers. This review aims to identify the theories and theoretical constructs used to understand adherence to TRBs during the pandemic within the UK social and legislative context.

METHODS

A systematic review identified studies to understand TRBs of adults in the UK during the pandemic. Identified theoretical constructs were coded to the Theoretical Domains Framework. Data are presented as a narrative summary.

RESULTS

Thirty-five studies (n = 211,209) investigated 123 TRBs, applied 13 theoretical frameworks and reported 50 sociodemographic characteristics and 129 psychological constructs. Most studies used social cognition theories to understand TRBs and employed cross-sectional designs. Risk of sampling bias was high. Relationships between constructs and TRBs varied, but in general, beliefs about the disease (e.g. severity and risk perception) and about TRBs (e.g. behavioural norms) influenced behavioural intentions and self-reported adherence. More studies than not found that older people and females were more adherent.

CONCLUSIONS

Behavioural scientists in the UK generated a significant and varied body of work to understand TRBs during the pandemic. However, more use of theories that do not rely on deliberative processes to effect behaviour change and study designs better able to support causal inferences should be used in future to inform public health policy and practice.

PROSPERO REGISTRATION

CRD42021282699.

Effectiveness of de-implementation strategies for low-value prescribing in secondary care: a systematic review

BACKGROUND/AIMS

Considerable efforts have been made to improve guideline adherence in healthcare through de-implementation, such as decreasing the prescription of inappropriate medicines. However, we have limited knowledge about the effectiveness, barriers, facilitators and consequences of de-implementation strategies targeting inappropriate medication prescribing in secondary care settings. This review was conducted to understand these factors to contribute to better replication and optimisation of future de-implementation efforts to reduce low-value care.

METHODS

A systematic review of randomised control trials was conducted. Papers were identified through CINAHL, EMBASE, MEDLINE and Cochrane register of controlled trials to February 2021. Eligible studies were randomised control trials evaluating behavioural strategies to de-implement inappropriate prescribing in secondary healthcare. Risk of bias was assessed using the Cochrane Risk of Bias tool. Intervention characteristics, effectiveness, barriers, facilitators and consequences were identified in the study text and tabulated.

RESULTS

Eleven studies were included, of which seven were reported as effectively de-implementing low-value prescribing. Included studies were judged to be mainly at low to moderate risk for selection biases and generally high risk for performance and reporting biases. The majority of these strategies were clinical decision support at the 'point of care'. Clinical decision support tools were the most common and effective. They were found to be a low-cost and simple strategy. However, barriers such as clinician's reluctance to accept recommendations, or the clinical setting were potential barriers to their success. Educational strategies were the second most reported intervention type however the utility of educational strategies for de-implementation remains varied. Multiple barriers and facilitators relating to the environmental context, resources and knowledge were identified across studies as potentially influencing de-implementation. Various consequences were identified; however, few measured the impact of de-implementation on usual appropriate practice.

CONCLUSION

This review offers insight into the intervention strategies, potential barriers, facilitators and consequences that may affect the de-implementation of low-value prescribing in secondary care. Identification of these key features helps understand how and why these strategies are effective and the wider (desirable or undesirable) impact of de-implementation. These findings can contribute to the successful replication or optimisation of strategies used to de-implement low-value prescribing practices in future.

TRIAL REGISTRATION

The review protocol was registered at PROSPERO (ID: CRD42021243944).

Using a behavioural approach to explore the factors that affect questionnaire return within a clinical trial: a qualitative study based on the theoretical domains framework

Objectives

To identify barriers and enablers to participant retention in trials requiring questionnaire return using the theoretical domains framework (TDF).

Study design and setting

We identified and subsequently invited participants who did not return at least one questionnaire during their participation in a clinical trial for one-to-one semi-structured telephone interviews. We used a behavioural framework (TDF) to explore whether any of the behavioural domains (eg, beliefs about consequences, emotion) affected questionnaire return. Thereafter, we generated a series of belief statements which summarised the content of participants’ main responses and coded these under separate themes.

Participants

We distributed invites to 279 eligible individuals and subsequently interviewed 9 participants who took part in the C-Gall trial. The C-Gall trial required participants to complete five postal questionnaires during their participation.

Results

Nine participants were interviewed. We developed 7 overarching themes which were relevant for returning postal questionnaires and identified both barriers and enablers from 11 core domains: knowledge; beliefs about consequences; environmental context and resources; reinforcement; emotion; beliefs about capabilities; behavioural regulation; social professional role and identity; skills; intentions and goals. Relevant content coded under these salient domains were categorised into seven key themes: unclear expectations of trial participation, personal attributes for questionnaire return, commitment to returning questionnaires given other priorities, sources of support in returning the questionnaires, individual preferences for presentation mode and timing of the questionnaires, internal and external strategies to encourage questionnaire return and the significance of questionnaire non-return.

Conclusion

We demonstrate how a behavioural approach may be useful for clinical trials associated with significant participation burden (e.g. trials that require multiple questionnaire responses), acting as the essential groundwork for the development of appropriate evidence-based solutions to combat retention issues.

Trial registration number

55215960; Pre-results.

What influences adherence to guidance for postoperative instillation of intravesical chemotherapy to patients with bladder cancer?

OBJECTIVE

To understand the barriers and facilitators to single instillation of intravesical chemotherapy (SI-IVC) use after resection of non-muscle-invasive bladder cancer (NMIBC) in Scotland and England using a behavioural theory-informed approach.

SUBJECTS AND METHODS

In a cross-sectional descriptive study of practices at seven hospitals, we investigated care pathways, policies, and interviewed 30 urology staff responsible for SI-IVC. We used the Theoretical Domains Framework (TDF) to organise our investigation and conducted deductive thematic analyses, while inductively coding emergent beliefs.

RESULTS

Barriers to SI-IVC were present at different organisational levels and professional roles. In four hospitals, there was a policy to not instil SI-IVC in theatre. Six hospitals' staff reported delays in mitomycin C (MMC) ordering and/or local storage. Lack of training, skills and perceived workload affected motivation. Facilitators included access to modern instilling devices (four hospitals) and incorporating reminders in operation proforma (four hospitals). Performance targets (with audit and feedback) within a national governance framework were present in Scotland but not England. Differences in coordinated leadership, sharing best practices, and disliking being perceived as underperforming, were evident in Scotland.

CONCLUSIONS

High-certainty evidence shows that SI-IVC, such as MMC, after NMIBC resection reduces recurrences. This evidence underpins international guidance. The number of eligible patients receiving SI-IVC is variable indicating suboptimal practice. Improving SI-IVC adherence requires modifications to theatre instilling policies, delivery and storage of MMC, staff training, and documentation. Centralising care, with bladder cancer expert leadership and best practices sharing with performance targets, likely led to improvements in Scotland. National quality improvement, incorporating audit and feedback, with additional implementation strategies targeted to professional role could improve adherence and patient outcomes elsewhere. This process should be controlled to clarify implementation intervention effectiveness.

Communication styles in the cancer consultation: preferences for a patient-centred approach

OBJECTIVE

Although doctor-patient communication has been the focus of numerous studies, there is a lack of empirical evidence on which to base a curriculum for teaching effective communication skills for use in an oncology setting. Research within the general practice area identifies patient-centred and doctor-centred behaviours as the most important dimensions of doctor-patient communication. This study examined patients and their relatives/friends' preferences for and satisfaction with patient-centred and doctor-centred consulting styles. It was argued that by determining patient preferences for consulting styles, specific recommendations for improving communication in the oncology setting could be formulated.

PARTICIPANTS AND METHODS

One hundred and thirteen women who had been treated for breast cancer and 48 of their relatives or friends watched videotaped scenarios of an oncology consultation, using professional actors. Viewers were randomly allocated to either a good prognosis or poor prognosis video, in which the oncologist discussed the patient's diagnosis, treatment and prognosis. These segments were presented in both styles to allow viewers to directly compare and contrast the patient-centred and doctor-centred approach. Outcomes included style preference and satisfaction. Demographic details, information and involvement preferences, anxiety and depression levels were also obtained.

RESULTS

Both patients and their relatives or friends significantly preferred a patient-centred consulting style across all aspects of the consultation (p<0.0001), except within the treatment segment of the good prognosis video where there was no significant difference. One third of the viewers preferred a doctor-centred style for the treatment and prognosis segments. Predictors of a patient-centred style preference in the treatment and prognosis segments included watching a poor prognosis video (OR=2.45, 95% CI 1.04-5.81, p=0.04; OR=3.22, 95% CI 1.22-8.50, p=0.02, respectively), and being employed in a professional occupation (OR=2.38, 95% CI 1.02-5.53, p=0.04 for the treatment segment only). Satisfaction ratings varied within and across videos.

CONCLUSION

Despite some methodological limitations, this study provides empirical data indicating that patients and their relatives or friends prefer a patient-centred approach to the consultation, particularly when the patient has a poor prognosis. The fact that a substantial minority of patients preferred a doctor-centred style emphasizes the need to enhance physicians' abilities to recognize different patient needs throughout the consultation.

Allogeneic blood stem cell and bone marrow transplantation for acute myelogenous leukemia and myelodysplasia: influence of stem cell source on outcome

We have compared the outcomes of 87 patients with acute myelogenous leukemia (AML) and myelodysplasia (MDS) receiving matched sibling transplants with stem cells from peripheral blood (blood cell transplant, BCT) or bone marrow (BMT). In good risk patients (AML in CR1) granulocytes recovered to 0.5 x 10(9)/l a median of 14 days after BCT compared with 19 days after BMT (P < 0.0001). For patients with poor risk disease (AML beyond CR1 and MDS) corresponding figures were 16 vs 26 days (P < 0.0001). Platelet recovery to 20 x 10(9)/l was also faster after BCT (good risk 12 vs 20 days, P < 0.0001; poor risk 17 vs 22 days, P = 0.04). Red cell transfusions were unaffected by cell source, but BCT recipients required less platelet transfusions (good risk 1 vs 5, P = 0.002; poor risk 5 vs 11, P = 0.004). Blood cell transplants resulted in more chronic GVHD (86% vs 48%, P = 0.005) and a significantly higher proportion of recipients with KPS of 80% or less (48% vs 5%, P = 0.004). Disease-free survival at 4 years was 23% for both groups of poor risk patients but outcome in good risk patients was better after BCT (93% vs 62%, P = 0.047) related mainly to less relapse. While disease-free survival may be better after BCT than BMT for AML in CR1, quality of life may be relatively impaired.

Trichomonas gallinae in budgerigars and columbid birds in Perth, Western Australia

OBJECTIVE

To estimate the prevalence of infection with Trichomonas gallinae and other parasites of the alimentary tract in psittacine and columbid birds in Perth and to determine in vitro the effectiveness of drugs commonly recommended for treating trichomoniasis.

DESIGN AND PROCEDURES

Samples of crop contents were collected from aviary flocks of budgerigars (Melopsittacus undulatus) and other psittacine and columbid birds in both private and commercial collections in Perth. Similar samples from wild Senegal doves (Streptopelia senegalensis) also were collected. Crop contents were examined and cultured for Trichomonas gallinae and in vitro studies were conducted on the susceptibility of isolates to several drugs used commonly. Other parasites also were detected by faecal examination and/or necropsy.

RESULTS

T gallinae was recovered from birds in 1 of 13 private collections of budgerigars (2/289 birds in total). Direct wet-mount examination of crop fluid identified 36.4% of samples at four commercial bird dealers which were later determined by culture to contain T gallinae. The prevalence of T gallinae infection range from 0 to 11.4% in budgerigars. The prevalence of T gallinae infection of wild Senegal doves was 46% and from one flock of racing pigeons was 59%. The in vitro minimum lethal concentrations of metronidazole, dimetridazole and ronidazole ranged from 40 to 96, 30 to 80 and 40 to 92 micrograms/mL respectively for six isolates of T gallinae. Other alimentary parasites detected during the survey included Spironucleus sp (syn. Hexamita sp), coccidia, Ascaridia platycerci and Raillietina sp.

CONCLUSIONS

Thirteen budgerigar flocks belonging to members of avicultural societies in Perth had a low prevalence of trichomoniasis and other parasitic infections. The dose rate currently recommended for ronidazole may not result in complete protozoacidal activity against T gallinae infection.

Behavioral and cognitive-behavioral approaches to chronic pain: recent advances and future directions

Behavioral and cognitive-behavioral approaches to chronic pain are receiving increasing attention from researchers and clinicians. This article reviews and highlights recent research advances and future research directions. Assessment research reviewed includes studies examining the social context of pain, the relationship of chronic pain to depression, cognitive variables affecting pain, and comprehensive assessment measures. Treatment outcome studies reviewed are those evaluating the effects of behavioral and cognitive-behavioral treatments for chronic pain. These studies focus on comparisons of behavioral treatment with control conditions, comparisons of two behavioral treatments, and prevention of chronic pain. Future directions for assessment and treatment research are outlined.

Behavioral and cognitive-behavioral approaches to chronic pain: Recent advances and future directions

Behavioral and cognitive-behavioral approaches to chronic pain are receiving increasing attention from researchers and clinicians. This article reviews and highlights recent research advances and future research directions. Assessment research reviewed includes studies examining the social context of pain, the relationship of chronic pain to depression, cognitive variables affecting pain, and comprehensive assessment measures. Treatment outcome studies reviewed are those evaluating the effects of behavioral and cognitive-behavioral treatments for chronic pain. These studies focus on comparisons of behavioral treatment with control conditions, comparisons of two behavioral treatments, and prevention of chronic pain. Future directions for assessment and treatment research are outlined.

Turnover of Sodium and Water by Free-Living Rabbits, Oryctolagus Cuniculus

Four places in New South Wales were chosen that had a permanent water supply and vegetation with very low or very high Na content, or no surface water during the study and medium, or low to medium, Na content. Wild rabbits (Oryctolagus cuniculus) were caught in those places, given 22NaCl and 3H2O by intraperitoneal injection and held for 4 to 5 h, then blood samples were taken and the rabbits were weighed, marked and released at the point of capture. After another 8 to 23 days they were recaptured and weighed, and blood samples were taken. Between the 7 or 8 values for different places and dates, mean bodyweight ranged from 937 to 1650 g, exchangeable Na from 37.37 to 50.10 mEq/kg bodyweight or 48.78 to 67.93 mEq/litre body water, Na turnover from 0.51 to 13.95 mEq/kg bodyweight daily, Na biological half-life from 2.3 to 55.0 days, total body water 677 to 777 ml/kg, water turnover 88 to 375 ml/kg daily and water half-life 1.4 to 5.6 days. Mean values are for groups of 4 to 25 rabbits. Between the 4 places, water content of vegetation ranged from 142 to 832 mg/kg fresh vegetation and, including 2 sites at one of the 4 places, Na content ranged from 0.51 to 20.98 mEq/kg fresh and 2.41 to 124.9 mEq/kg dry matter. There was a positive linear relation between Na in fresh vegetation and Na turnover rate in rabbits. The relation between water content of vegetation and water turnover in rabbits was not precise, because probably of such factors as diet selection, rain and accessibility and use of water. Lactation may have a strong effect on rabbits when water or Na is scarce, because rabbits may not ingest the faeces and urine of their young like other animals.Low rate of water turnover, especially after metabolic weight correction, demonstrated the efficiency of water conservation of rabbits and partly explained their success in dry places. Published values for other species are compared. Food items were not identified in the present work, but identification and analysis of their Na content would allow qualitative calculation of the food intake of free-living herbivores from their Na turnover.