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Kulkarni AJ, Thiagarajan AB, Skolarus TA, Krein SL, Ellimoottil C. Attitudes and barriers toward video visits in surgical care: Insights from a nationwide survey among surgeons. Surgery 2024:S0039-6060(24)00198-3. [PMID: 38734503 DOI: 10.1016/j.surg.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/16/2024] [Accepted: 03/21/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Surgeons rapidly adopted video visits during the COVID-19 pandemic. However, video visit use among surgeons has significantly declined, pointing to the need to better understand current attitudes and barriers to their use in surgical care. METHODS From August 2022 to March 2023, a nationwide survey was conducted among practicing surgeons in 6 specialties. The survey included multiple-choice and free-response questions based on an implementation determinants framework, covering demographics, provider, patient, and organizational factors. RESULTS A total of 170 surgeons responded (24% response rate). Overall, 67% of surgeons said their practice lacked motivation for video visit implementation. Additionally, 69% disagreed with using video visits as the sole means for preoperative surgical consultation, even with relevant medical history, labs, and imaging. Nearly 43% cited the need for a physical examination, whereas 58% of surgeons said video visits carried a greater malpractice risk than in-person visits. Other barriers included technological limitations, billing, and care quality concerns. Nevertheless, 41% agreed that video visits could improve outcomes for some patients, and 60% expressed openness to using video visits exclusively for postoperative consultations in uncomplicated surgeries. CONCLUSION Surgeons recognize the potential benefits of video visits for certain patients. However, perceived barriers include the need for a physical examination, technological limitations, care quality concerns, and malpractice risks.
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Affiliation(s)
- Ashwin J Kulkarni
- Department of Urology, University of Michigan, Ann Arbor, MI; University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, Ann Arbor, MI.
| | - Anagha B Thiagarajan
- Helen Diller Family Comprehensive Cancer Center at UCSF, San Francisco, CA; Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Ted A Skolarus
- Department of Surgery, Section of Urology, University of Chicago, IL
| | - Sarah L Krein
- University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, Ann Arbor, MI; Department of Veterans Affairs, Ann Arbor Healthcare System, MI
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, Ann Arbor, MI. https://twitter.com/chadellimoottil
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Hyman MJ, Skolarus TA, Cabral J, Shewmon K, Bedziner M, Agarwal PK, Modi PK. Utilization and Timing of Cystoscopy for Hematuria Evaluation by Advanced Practice Providers and Urologists. Urology 2024:S0090-4295(24)00291-7. [PMID: 38663584 DOI: 10.1016/j.urology.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE To characterize differences between urologists and advanced practice providers (APPs) in the utilization of cystoscopy for hematuria. METHODS We identified patients initially evaluated for hematuria by a urologist or urology APP between 2015 and 2020 in the MarketScan Research Databases. We determined whether they received a cystoscopy within 6 months of their urology visit and the number of days until cystoscopy. We used multivariable regression to analyze the association between these outcomes and whether the urology clinician was an advanced practice registered nurse (APRN), physician assistant (PA), or urologist. RESULTS We identified 34,470 patients with microscopic hematuria and 17,328 patients with gross hematuria. Patients evaluated by urologists more often received a same-day cystoscopy than those evaluated by APPs (13% vs 5.8%). The odds that patients evaluated for microscopic and gross hematuria received a cystoscopy were 46.2% and 26.2% lower, respectively, if they were evaluated by an APRN vs a urologist. Patients seeing an APRN for microscopic and gross hematuria also waited approximately 7 and 14 days longer for their cystoscopy, respectively. No differences were observed for patients evaluated by PAs vs urologists. CONCLUSION Patients evaluated for hematuria by an APRN were less likely to receive a cystoscopy and had a longer wait until the procedure compared to those evaluated by a urologist; however, no differences were observed between PAs and urologists. Better understanding APP integration into urology clinics is warranted.
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Affiliation(s)
- Max J Hyman
- The Center for Health and the Social Sciences, The University of Chicago, Chicago, IL
| | - Ted A Skolarus
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Joshua Cabral
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Kate Shewmon
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Moshe Bedziner
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Piyush K Agarwal
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Parth K Modi
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL.
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Skolarus TA, Hawley ST, Forman J, Sales AE, Sparks JB, Metreger T, Burns J, Caram MV, Radhakrishnan A, Dossett LA, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Dunsmore J, Maclennan S, Saini S, Hollenbeck BK, Shahinian V, Wittmann DA, Deolankar V, Sriram S. Unpacking overuse of androgen deprivation therapy for prostate cancer to inform de-implementation strategies. Implement Sci Commun 2024; 5:37. [PMID: 38594740 PMCID: PMC11005280 DOI: 10.1186/s43058-024-00576-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/04/2024] [Indexed: 04/11/2024] Open
Abstract
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.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Surgery, Urology Section, University of Chicago, Chicago, USA.
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Anne E Sales
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer Burns
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Megan V Caram
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Archana Radhakrishnan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | - Jeremy B Shelton
- VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
- Department of Urology, University of California, Los Angeles, USA
| | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer Dunsmore
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Steven Maclennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sameer Saini
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Varad Deolankar
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
| | - S Sriram
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
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Stensland KD, Caram MEV, Herr DJ, Burns JA, Sparks JB, Elliott DA, Shin C, Morgan TM, Zaslavsky A, Hollenbeck BK, Tsodikov A, Skolarus TA. National Long-term Survival Estimates After Radical Prostatectomy for Prostate Cancer. Urology 2024; 184:135-141. [PMID: 37951360 DOI: 10.1016/j.urology.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 11/13/2023]
Abstract
OBJECTIVE To examine survival and disease control outcomes, including metastasis-related survival outcomes, in a large contemporary cohort of patients undergoing radical prostatectomy for localized prostate cancer. METHODS We conducted a retrospective study of men with localized prostate cancer treated with radical prostatectomy from 2005 to 2015 with follow-up through 2019 in the Veterans Health Administration. We defined biochemical recurrence (BCR) as a prostate-specific antigen ≥0.2 ng/mL. We used a validated natural language processing encoded dataset to identify incident metastatic prostate cancer. We estimated overall survival from time of surgery, time of BCR, and time of first metastasis using the Kaplan-Meier method. We then estimated time from surgery to BCR, BCR to metastatic disease, and prostate-cancer-specific survival from various time points using cumulative incidence considering competing risk of death. RESULTS Of 21,992 men undergoing radical prostatectomy, we identified 5951 (27%) who developed BCR. Of men with BCR, 677 (11%) developed metastases. We estimated the 10-year cumulative incidence of BCR and metastases after BCR were 28% and 20%, respectively. Median overall survival after BCR was 14years, with 10-year survival of 70%. From the time of metastasis, median overall survival approached 7years, with 10-year overall survival of 34%. Prostate cancer-specific survival for the entire cohort at 10years was 94%. CONCLUSION In this large contemporary national cohort, survival for men with biochemically recurrent prostate cancer is longer than historical cohorts. When counseling patients and designing clinical studies, these updated estimates may serve as more reliable reflections of current outcomes.
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Affiliation(s)
| | - Megan E V Caram
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel J Herr
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Jennifer A Burns
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B Sparks
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - David A Elliott
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Chris Shin
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI
| | | | | | | | - Ted A Skolarus
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL.
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Radhakrishnan A, Subramanian L, Rankin AJ, Fetters MD, Wittmann DA, Ginsburg KB, Hawley ST, Skolarus TA. Primary Care Physician and Urologist Perspectives on Optimizing Active Surveillance for Low-Risk Prostate Cancer. Ann Fam Med 2024; 22:5-11. [PMID: 38253492 DOI: 10.1370/afm.3057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 01/24/2024] Open
Abstract
PURPOSE We conducted a study to understand primary care physician (PCP) and urologist perspectives on determinants of active surveillance care delivery for men with low-risk prostate cancer. METHODS We conducted in-depth, semistructured, virtual interviews with a purposive sample of 19 PCPs and 15 urologists between June 2020 and March 2021. We used the behavioral theory-informed Theoretical Domains Framework to understand barriers to and facilitators of active surveillance care delivery. Interviews were recorded, transcribed, and deductively coded into framework domains and constructs by 3 independent coders. Participant recruitment continued until data saturation by group. RESULTS Our study included 19 PCPs (9 female; 4 in community practices, 15 in academic medical centers) and 15 urologists (3 female; 5 in private practice, 3 in academic medical centers). The most commonly reported Theoretical Domains Framework domains affecting active surveillance care were (1) knowledge and (2) environmental context and resources. Although urologists were knowledgeable about active surveillance, PCPs mentioned limitations in their understanding of active surveillance (eg, what follow-up entails). Both groups noted the importance of an informed patient, especially how a patient's understanding of active surveillance facilitates their receipt of recommended follow-up. Physicians viewed patient loss to follow-up as a barrier, but identified a favorable organizational culture/climate (eg, good communication between physicians) as a facilitator. CONCLUSIONS With patients increasingly involving their PCPs in their cancer care, our study presents factors both PCPs and urologists perceive (or identify) as affecting optimal active surveillance care delivery. We provide insights that can help inform multilevel supportive interventions for patients, physicians, and organizations to ensure the success of active surveillance as a management strategy for low-risk prostate cancer.
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Affiliation(s)
- Archana Radhakrishnan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lalita Subramanian
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Aaron J Rankin
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Kevin B Ginsburg
- Department of Urology, Wayne State University, Detroit, Michigan
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Ted A Skolarus
- Department of Urology, University of Chicago, Chicago, Illinois
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Nguyen CB, Kobe C, Kumbier KE, Bauman J, Burns JA, Tsao PA, Sparks JB, Skolarus TA, Caram ME. Determinants of Bone-Modifying Agent Prescribing for Metastatic Castration-Resistant Prostate Cancer in a National Health Care Delivery System. JCO Oncol Pract 2024; 20:59-68. [PMID: 38085028 PMCID: PMC10827294 DOI: 10.1200/op.23.00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/07/2023] [Accepted: 09/27/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE Despite guidelines recommending bone-modifying agents (BMAs) to decrease skeletal-related events (SREs) in men with metastatic castration-resistant prostate cancer (mCRPC), BMAs are underutilized. In this retrospective cohort study, we report the factors associated with BMA use in a national health care delivery system. METHODS We used the Veterans Affairs Corporate Data Warehouse to identify men with mCRPC between 2010 and 2017. BMA prescribing frequency was evaluated, and the association between patient- and disease-specific factors with BMA use was assessed using multivariable logistic regression. RESULTS Among 3,980 men identified with mCRPC (mean age 73.5 years, 29% Black), 47% received a BMA; median time to BMA from start of mCRPC treatment was 102 days. Factors associated with BMA use included previous BMA use (adjusted odds ratio [aOR], 7.81 [95% CI, 6.48 to 9.47]), diagnosis code for bone metastases (aOR, 1.26 [95% CI, 1.08 to 1.46]), and concomitant corticosteroid use (aOR, 1.53 [95% CI, 1.29 to 1.82]). Decreased BMA use was associated with advancing age (aOR, 0.85 per 10 years [95% CI, 0.78 to 0.92]), Charlson comorbidity index ≥2 (aOR, 0.76 [95% CI, 0.63 to 0.93]), Black race (aOR, 0.83 [95% CI, 0.70 to 0.98]), and decreased estimated glomerular filtration rate (eGFR; aOR, 0.19 [95% CI, 0.11 to 0.32] for eGFR 0-29 mL/minutes; aOR, 0.76 [95% CI, 0.64 to 0.91] for 30-59 mL/minutes). CONCLUSION Patients who are older, Black, or have more comorbidities are less likely to receive guideline concordant care to prevent SREs. These observations highlight the unique challenges of caring for patients with mCRPC and the need for future studies to increase BMA use in these populations.
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Affiliation(s)
- Charles B. Nguyen
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Christopher Kobe
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kyle E. Kumbier
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan Bauman
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer A. Burns
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Phoebe A. Tsao
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B. Sparks
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Ted A. Skolarus
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Surgery, Section of Urology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Megan E.V. Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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7
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Subramanian L, Hawley ST, Skolarus TA, Rankin A, Fetters MD, Witzke K, Chen J, Radhakrishnan A. Patient perspectives on factors influencing active surveillance adherence for low-risk prostate cancer: A qualitative study. Cancer Med 2023; 13:e6847. [PMID: 38151901 PMCID: PMC10807559 DOI: 10.1002/cam4.6847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/09/2023] [Accepted: 12/11/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND Prostate cancer is the most common cancer among men in the United States. Treatment guidelines recommend active surveillance for low-risk prostate cancer, which involves monitoring for progression, to avoid or delay definitive treatments and their side effects. Despite increased uptake, adherence to surveillance remains a challenge. METHODS We conducted semi-structured, qualitative, virtual interviews based on the Theoretical Domains Framework (TDF), with men (15) who were or had been on active surveillance for their low-risk prostate cancer in 2020. Interviews were transcribed and coded under TDF's behavioral theory-based domains. We analyzed domains related to adherence to surveillance using constructivist grounded theory to identify themes influencing decision processes in adherence. RESULTS The TDF domains of emotion, beliefs about consequences, environmental context and resources, and social influences were most relevant to surveillance adherence-. From these four TDF domains, three themes emerged as underlying decision processes: trust in surveillance as treatment, quality of life, and experiences of self and others. Positive perceptions of these three themes supported adherence while negative perceptions contributed to non-adherence (i.e., not receiving follow-up or stopping surveillance). The relationship between the TDF domains and themes provided a theoretical process describing factors impacting active surveillance adherence for men with low-risk prostate cancer. CONCLUSIONS Men identified key factors impacting active surveillance adherence that provide opportunities for clinical implementation and practice improvement. Future efforts should focus on multi-level interventions that foster trust in surveillance as treatment, emphasize quality of life benefits and enhance patients' interpersonal experiences while on surveillance to optimize adherence.
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Affiliation(s)
- Lalita Subramanian
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Sarah T. Hawley
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management Research, Health Services Research & DevelopmentVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Center for Clinical Management Research, Health Services Research & DevelopmentVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Department of Surgery, Urology SectionUniversity of ChicagoChicagoIllinoisUSA
| | - Aaron Rankin
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | | | - Karla Witzke
- Department of UrologyMyMichigan HealthMidlandMichiganUSA
| | - Jason Chen
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Archana Radhakrishnan
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management Research, Health Services Research & DevelopmentVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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Polcari K, Hyman MJ, Skolarus TA, Sales AE, Meltzer DO, Modi PK. Industry Payments for Vibegron and Prescribing Patterns Among Urologic Clinicians. JAMA Health Forum 2023; 4:e234020. [PMID: 38127590 PMCID: PMC10739068 DOI: 10.1001/jamahealthforum.2023.4020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/18/2023] [Indexed: 12/23/2023] Open
Abstract
This cross-sectional study compares the prescribing practices among urologists and advanced practice clinicians who received vs did not receive payment from drug manufacturers.
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Affiliation(s)
- Kayla Polcari
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Max J. Hyman
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
| | - Ted A. Skolarus
- Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Anne E. Sales
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Family and Community Medicine, University of Missouri, Columbia
- Sinclair School of Nursing, University of Missouri School of Medicine, Columbia
| | - David O. Meltzer
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
- Department of Medicine and Economics, Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois
| | - Parth K. Modi
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
- Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois
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Singhal U, Hollenbeck BK, Kaffenberger SD, Salami SS, George AK, Skolarus TA, Montgomery JS, Wittmann DA, Miller DC, Wei JT, Palapattu GS, Montie JE, Dunn RL, Morgan TM. Comparing Patient-reported Functional Outcomes After Radical Prostatectomy in Historical and Contemporary Practice. J Urol 2023; 210:771-777. [PMID: 37566643 DOI: 10.1097/ju.0000000000003646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
PURPOSE Modifications to surgical technique, particularly the widespread adoption of robotic surgery, have been proposed to improve functional recovery after prostate cancer surgery. However, rigorous comparison of men in historical vs contemporary practice to evaluate the cumulative effect of these changes on urinary and sexual function after radical prostatectomy is lacking. MATERIALS AND METHODS We compared prospectively collected patient-reported urinary and sexual function from historical (PROSTQA [Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment study], n=235) and contemporary (MUSIC-PRO [Michigan Urological Surgery Improvement Collaborative Patient Reported Outcome] registry, n=1,215) cohorts at the University of Michigan to understand whether modern techniques have resulted in functional improvements for men undergoing prostate cancer surgery. RESULTS We found significant differences in baseline function, with better urinary (median [IQR]; 100 [93.8-100] vs 93.8 [85.5-100], P < .001) and sexual scores (median [IQR]; 83.3 [66.7-100] vs 74.4 [44.2-87.5], P < .001) prior to treatment in PROSTQA compared to MUSIC-PRO patients, respectively. There was no statistically significant difference in the pattern of urinary incontinence recovery after surgery from 6-24 months between groups (P = .14). However, men in the contemporary MUSIC-PRO group did have significantly better recovery of sexual function compared to men in the historical PROSTQA group (P < .0001). Further, we found that contemporary practice consists of men with more unfavorable demographic and clinical characteristics compared to historical practice. CONCLUSIONS Our results demonstrate that the widespread alterations in prostate cancer surgery over the past 2 decades have yielded improvements in sexual, but not urinary, function recovery.
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Affiliation(s)
- Udit Singhal
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Brent K Hollenbeck
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Samuel D Kaffenberger
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Simpa S Salami
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Arvin K George
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ted A Skolarus
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Jeffrey S Montgomery
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Daniela A Wittmann
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - John T Wei
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Ganesh S Palapattu
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - James E Montie
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Rodney L Dunn
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Todd M Morgan
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
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10
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Herr DJ, Elliott DA, Duchesne G, Stensland KD, Caram ME, Chapman C, Burns JA, Hollenbeck BK, Sparks JB, Shin C, Zaslavsky A, Tsodikov A, Skolarus TA. Outcomes after definitive radiation therapy for localized prostate cancer in a national health care delivery system. Cancer 2023; 129:3326-3333. [PMID: 37389814 PMCID: PMC10528965 DOI: 10.1002/cncr.34916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/10/2023] [Accepted: 05/18/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Accurate information regarding real-world outcomes after contemporary radiation therapy for localized prostate cancer is important for shared decision-making. Clinically relevant end points at 10 years among men treated within a national health care delivery system were examined. METHODS National administrative, cancer registry, and electronic health record data were used for patients undergoing definitive radiation therapy with or without concurrent androgen deprivation therapy within the Veterans Health Administration from 2005 to 2015. National Death Index data were used through 2019 for overall and prostate cancer-specific survival and identified date of incident metastatic prostate cancer using a validated natural language processing algorithm. Metastasis-free, prostate cancer-specific, and overall survival using Kaplan-Meier methods were estimated. RESULTS Among 41,735 men treated with definitive radiation therapy, the median age at diagnosis was 65 years and median follow-up was 8.7 years. Most had intermediate (42%) and high-risk (33%) disease, with 40% receiving androgen deprivation therapy as part of initial therapy. Unadjusted 10-year metastasis-free survival was 96%, 92%, and 80% for low-, intermediate-, and high-risk disease. Similarly, unadjusted 10-year prostate cancer-specific survival was 98%, 97%, and 90% for low-, intermediate-, and high-risk disease. The unadjusted overall survival was lower across increasing disease risk categories at 77%, 71%, and 62% for low-, intermediate-, and high-risk disease (p < .001). CONCLUSIONS These data provide population-based 10-year benchmarks for clinically relevant end points, including metastasis-free survival, among patients with localized prostate cancer undergoing radiation therapy using contemporary techniques. The survival rates for high-risk disease in particular suggest that outcomes have recently improved.
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Affiliation(s)
- Daniel J. Herr
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - David A. Elliott
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
- Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | | | | | - Megan E.V. Caram
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Jennifer A. Burns
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Jordan B. Sparks
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Chris Shin
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | | | | | - Ted A. Skolarus
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL
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11
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Reed S, Singh A, Hyman MJ, Meltzer DO, Sales AE, Skolarus TA, Modi PK. Industry Payments to Urologists and Urologic Advanced Practice Providers in 2021. Urology 2023; 180:121-129. [PMID: 37517679 DOI: 10.1016/j.urology.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To compare industry payments from drug and medical device companies to urologists and urologic advanced practice providers (APPs) in 2021. METHODS We used the 2020 Medicare Data on Provider Practice and Specialty file to identify single-specialty urology practices, defined as those where the majority of physicians were urologists. We then used the Open Payments Program Year 2021 data to summarize the value and number of industry payments to urologists and APPs, including nurse practitioners and physician assistants, in these practices. We calculated the total value and number of payments and median total value and number of payments per provider for urologists and urologic APPs. RESULTS We identified 4418 urologists and 1099 APPs working in single-specialty urology practices in 2021 (Table 1). Of these, 3646 (87%) urologists received at least one industry payment, totaling $14,755,003 from 116,039 payments, and 954 urologic APPs (87%) received at least one industry payment, including 463 nurse practitioners (85%), totaling $401,283 from 13,035 payments, and 491 physician assistants (89%), totaling $543,429 from 14,626 payments. We observed significantly greater median total value and number of payments per provider for urologists ($620 and 24 payments) compared to urologic APPs ($473 and 21 payments; P < .001 and P = .017, respectively). CONCLUSION A similar percentage of urologists and urologic APPs received industry payments in 2021. While urologists received a higher total number and total value of payments in 2021, urologic APPs were a common target of industry marketing payments.
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Affiliation(s)
| | - Armaan Singh
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Max J Hyman
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL
| | - David O Meltzer
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL
| | - Anne E Sales
- Sinclair School of Nursing, University of Missouri, Columbia, MO
| | - Ted A Skolarus
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL
| | - Parth K Modi
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL.
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12
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Stensland KD, Modi PK, Skolarus TA. Using Implementation Science to Improve Patient Care. J Urol 2023; 210:577-579. [PMID: 37578467 DOI: 10.1097/ju.0000000000003649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Kristian D Stensland
- University of Michigan, Ann Arbor, Michigan
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | - Ted A Skolarus
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Chicago, Chicago, Illinois
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13
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Hyman MJ, Skolarus TA, Litwack K, Meltzer DO, Modi PK. Outcomes of Hematuria Evaluation by Advanced Practice Providers and Urologists. Urology 2023; 178:67-75. [PMID: 37196831 DOI: 10.1016/j.urology.2023.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/02/2023] [Accepted: 03/13/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To examine the quality and costs of care for patients evaluated for hematuria by urologic advanced practice providers (APPs) and urologists. The roles of APPs in urology are growing, but their clinical and financial outcomes compared to urologists are not well understood. METHODS We conducted a retrospective cohort study of commercially insured patients using data from 2014 to 2020. We included adult beneficiaries with a diagnosis code for hematuria and an initial outpatient evaluation and management visit with a urologic APP or urologist. We assessed receipt of cystoscopy procedure, imaging study, bladder biopsy procedure, and bladder cancer diagnosis within 6 months of the initial visit. Secondary outcomes included the time until each of these outcomes occurred and the out-of-pocket spending and total payments. RESULTS We identified 59,923 patients who were initially evaluated for hematuria. Visits with urologic nurse practitioners rather than urologists were associated with significantly lower odds of receiving cystoscopy procedures (odds ratio [OR] 0.93, 95% confidence interval [95% CI] 0.54-0.72, P < .001), imaging studies (OR 0.79, 95% CI 0.69-0.91, P < .001), and bladder biopsy procedures (OR 0.61, 95% CI 0.41-0.92, P = .02). Visits with urologic physician assistants were associated with 11% greater out-of-pocket payments (incident risk ratio 1.11, CI 1.01-1.22, P = .02) and 14% greater total payments (incident risk ratio 1.14, CI 1.04-1.25, P = .004). CONCLUSION There are clinical and financial differences in hematuria care delivered by urologic APPs and urologists. The incorporation of APPs into urologic care warrants further study, and specialty-specific training for APPs should be considered.
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Affiliation(s)
- Max J Hyman
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL
| | - Ted A Skolarus
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL
| | - Kim Litwack
- College of Nursing, University of Wisconsin Milwaukee, Milwaukee, WI
| | - David O Meltzer
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL; Departments of Medicine and Economics, Harris School of Public Policy Studies, University of Chicago, Chicago, IL
| | - Parth K Modi
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL; Section of Urology, Department of Surgery, University of Chicago, Chicago, IL.
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14
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Tsao PA, Burns J, Kumbier K, Sparks JB, Entenman S, Bloor LE, Bohnert ASB, Skolarus TA, Caram MEV. Mental health care utilization among men with castration-resistant prostate cancer receiving abiraterone or enzalutamide. Cancer Med 2023; 12:16490-16501. [PMID: 37325888 PMCID: PMC10469813 DOI: 10.1002/cam4.6237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Abiraterone and enzalutamide are castration-resistant prostate cancer (CRPC) therapies with potentially distinct associations with mental health symptoms given their differing antiandrogen targets. METHODS We used national Veterans Health Administration data to identify patients with CRPC who received first-line abiraterone or enzalutamide from 2010 to 2017. Using Poisson regression, we compared outpatient mental health encounters per 100 patient-months on drug between the abiraterone and enzalutamide cohorts adjusting for patient factors (e.g., age). We compared mental health encounters in the year before versus after starting therapy using the McNemar test. RESULTS We identified 2902 CRPC patients who received abiraterone (n = 1992) or enzalutamide (n = 910). We found no difference in outpatient mental health encounters between the two groups (adjusted incident rate ratio [aIRR] 1.04, 95% confidence interval [CI] 0.95-1.15). However, men with preexisting mental health diagnoses received 81.3% of the outpatient mental health encounters and had higher rates of these encounters with enzalutamide (aIRR 1.21, 95% CI 1.09-1.34). Among patients with ≥1 year of enrollment before and after starting abiraterone (n = 1139) or enzalutamide (n = 446), there was no difference in mental health care utilization before versus after starting treatment (17.0% of patients vs. 17.6%, p = 0.60, abiraterone; 16.4% vs. 18.4%, p = 0.26, enzalutamide). CONCLUSION We found no overall differences in mental health care utilization between CRPC patients who received first-line abiraterone versus enzalutamide. However, men with preexisting mental health diagnoses received the majority of mental health care and had more mental health visits with enzalutamide.
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Affiliation(s)
- Phoebe A. Tsao
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Institute of Health Policy and Innovation, University of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Jennifer Burns
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Kyle Kumbier
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Jordan B. Sparks
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Shami Entenman
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Lindsey E. Bloor
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of PsychiatryVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Amy S. B. Bohnert
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Institute of Health Policy and Innovation, University of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of AnesthesiologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Department of Surgery, Section of UrologyUniversity of Chicago Pritzker School of MedicineChicagoIllinoisUSA
| | - Megan E. V. Caram
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Veterans Affairs Health Services Research & Development, Center for Clinical Management and ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Institute of Health Policy and Innovation, University of Michigan Medical SchoolAnn ArborMichiganUSA
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15
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Agochukwu-Mmonu N, Qin Y, Kaufman S, Oerline M, Vince R, Makarov D, Caram MV, Chapman C, Ravenell J, Hollenbeck BK, Skolarus TA. Understanding the Role of Urology Practice Organization and Racial Composition in Prostate Cancer Treatment Disparities. JCO Oncol Pract 2023; 19:e763-e772. [PMID: 36657098 PMCID: PMC10414720 DOI: 10.1200/op.22.00147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 09/13/2022] [Accepted: 11/07/2022] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Black men have a higher risk of prostate cancer diagnosis and mortality but are less likely to receive definitive treatment. The impact of structural aspects on treatment is unknown but may lead to actionable insights to mitigate disparities. We sought to examine the associations between urology practice organization and racial composition and treatment patterns for Medicare beneficiaries with incident prostate cancer. METHODS Using a 20% sample of national Medicare data, we identified beneficiaries diagnosed with prostate cancer between January 2010 and December 2015 and followed them through 2016. We linked urologists to their practices with tax identification numbers. We then linked patients to practices on the basis of their primary urologist. We grouped practices into quartiles on the basis of their proportion of Black patients. We used multilevel mixed-effects models to identify treatment associations. RESULTS We identified 54,443 patients with incident prostate cancer associated with 4,194 practices. Most patients were White (87%), and 9% were Black. We found wide variation in racial practice composition and practice segregation. Patients in practices with the highest proportion of Black patients had the lowest socioeconomic status (43.1%), highest comorbidity (9.9% with comorbidity score ≥ 3), and earlier age at prostate cancer diagnosis (33.5% age 66-69 years; P < .01). Black patients had lower odds of definitive therapy (adjusted odds ratio, 0.87; 95% CI, 0.81 to 0.93) and underwent less treatment than White patients in every practice context. Black patients in practices with higher proportions of Black patients had higher treatment rates than Black patients in practices with lower proportions. Black patients had lower predicted probability of treatment (66%) than White patients (69%; P < .05). CONCLUSION Despite Medicare coverage, we found less definitive treatment among Black beneficiaries consistent with ongoing prostate cancer treatment disparities. Our findings are reflective of the adverse effects of practice segregation and structural racism, highlighting the need for multilevel interventions.
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Affiliation(s)
- Nnenaya Agochukwu-Mmonu
- Department of Urology, New York University Medical Center, New York, NY
- Department of Population Health, New York University Medical Center, New York, NY
| | - Yongmei Qin
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Samuel Kaufman
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary Oerline
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Randy Vince
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Danil Makarov
- Department of Urology, New York University Medical Center, New York, NY
- Department of Population Health, New York University Medical Center, New York, NY
| | - Megan V. Caram
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI
- Department of Medicine, New York University Medical Center, New York, NY
| | - Christina Chapman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Joseph Ravenell
- Department of Population Health, New York University Medical Center, New York, NY
- Department of Medicine, New York University Medical Center, New York, NY
| | - Brent K. Hollenbeck
- Department of Urology, University of Michigan, Ann Arbor, MI
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI
| | - Ted A. Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
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16
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Stensland KD, Sales AE, Vedapudi VK, Damschroder LJ, Skolarus TA. Exploring implementation outcomes in the clinical trial context: a qualitative study of physician trial stakeholders. Trials 2023; 24:297. [PMID: 37106368 PMCID: PMC10142148 DOI: 10.1186/s13063-023-07304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Cancer clinical trials can be considered evidence-based interventions with substantial benefits, but suffer from poor implementation leading to low enrollment and frequent failure. Applying implementation science approaches such as outcomes frameworks to the trial context could aid in contextualizing and evaluating trial improvement strategies. However, the acceptability and appropriateness of these adapted outcomes to trial stakeholders are unclear. For these reasons, we interviewed cancer clinical trial physician stakeholders to explore how they perceive and address clinical trial implementation outcomes. METHODS We purposively selected 15 cancer clinical trial physician stakeholders from our institution representing different specialties, trial roles, and trial sponsor types. We performed semi-structured interviews to explore a previous adaptation of Proctor's Implementation Outcomes Framework to the clinical trial context. Emergent themes from each outcome were developed. RESULTS The implementation outcomes were well understood and applicable (i.e., appropriate and acceptable) to clinical trial stakeholders. We describe cancer clinical trial physician stakeholder understanding of these outcomes and current application of these concepts. Trial feasibility and implementation cost were felt to be most critical to trial design and implementation. Trial penetration was most difficult to measure, primarily due to eligible patient identification. In general, we found that formal methods for trial improvement and trial implementation evaluation were poorly developed. Cancer clinical trial physician stakeholders referred to some design and implementation techniques used to improve trials, but these were infrequently formally evaluated or theory-based. CONCLUSION Implementation outcomes adapted to the trial context were acceptable and appropriate to cancer clinical trial physician stakeholders. Use of these outcomes could facilitate the evaluation and design of clinical trial improvement interventions. Additionally, these outcomes highlight potential areas for the development of new tools, for example informatics solutions, to improve the evaluation and implementation of clinical trials.
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Affiliation(s)
- Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC, Building 16, 100S-12, Ann Arbor, MI, 48109, USA.
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Anne E Sales
- University of Missouri and Department of Family and Community Medicine, Sinclair School of Nursing, University of Missouri School of Medicine, Columbia, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC, Building 16, 100S-12, Ann Arbor, MI, 48109, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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17
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Soukup T, Winters D, Chua K, Rowland P, Moneke J, Skolarus TA, Bharathan R, Harling L, Bali A, Asher V, Gandamihardja T, Sevdalis N, Green JSA, Lamb BW. Evaluation of changes to work patterns in multidisciplinary cancer team meetings due to the COVID-19 pandemic: A national mixed-method survey study. Cancer Med 2023; 12:8729-8741. [PMID: 36647755 PMCID: PMC10134365 DOI: 10.1002/cam4.5608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND It is not well understood the overall changes that multidisciplinary teams (MDTs) have had to make in response to the COVID-19 pandemic, nor the impact that such changes, in addition to the other challenges faced by MDTs, have had on decision-making, communication, or participation in the context of MDT meetings specifically. METHODS This was a mixed method, prospective cross-sectional survey study taking place in the United Kingdom between September 2020 and August 2021. RESULTS The participants were 423 MDT members. Qualitative findings revealed hybrid working and possibility of virtual attendance as the change introduced because of COVID-19 that MDTs would like to maintain. However, IT-related issues, slower meetings, longer lists and delays were identified as common with improving of the IT infrastructure necessary going forward. In contrast, virtual meetings and increased attendance/availability of clinicians were highlighted as the positive outcomes resulting from the change. Quantitative findings showed significant improvement from before COVID-19 for MDT meeting organisation and logistics (M = 45, SD = 20) compared to the access (M = 50, SD = 12, t(390) = 5.028, p = 0.001), case discussions (M = 50, SD = 14, t(373) = -5.104, p = 0.001), and patient representation (M = 50, SD = 12, t(382) = -4.537, p = 0.001) at MDT meetings. DISCUSSION Our study explored the perception of change since COVID-19 among cancer MDTs using mixed methods. While hybrid working was preferred, challenges exist. Significant improvements in the meeting organisation and logistics were reported. Although we found no significant perceived worsening across the four domains investigated, there was an indication in this direction for the case discussions warranting further 'live' assessments of MDT meetings.
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Affiliation(s)
- Tayana Soukup
- Institute of Psychiatry, Psychology, and Neuroscience, Health Service and Population Research DepartmentKing's College LondonLondonUK
| | | | - Kia‐Chong Chua
- Institute of Psychiatry, Psychology, and Neuroscience, Health Service and Population Research DepartmentKing's College LondonLondonUK
| | - Philip Rowland
- Department of UrologyCambridge University Hospital NHS TrustLondonUK
| | - Jacqueline Moneke
- Department of UrologyCambridge University Hospital NHS TrustLondonUK
| | - Ted A. Skolarus
- Dow Division of Health Services Research, Department of UrologyUniversity of Michigan, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | | | - Leanne Harling
- Department of Surgery and CancerImperial College LondonLondonUK
- School of Cancer and Pharmaceutical ScienceKings College LondonLondonUK
| | - Anish Bali
- Gynaecology Cancer CentreUniversity Hospitals of Derby & BurtonDerbyUK
| | - Viren Asher
- Gynaecology Cancer CentreUniversity Hospitals of Derby & BurtonDerbyUK
| | | | - Nick Sevdalis
- Institute of Psychiatry, Psychology, and Neuroscience, Health Service and Population Research DepartmentKing's College LondonLondonUK
| | | | - Benjamin W. Lamb
- Department of UrologyBarts Health NHS TrustLondonUK
- Bart’s Cancer InstituteQueen Mary University of LondonLondonUK
- Department of UrologyUniversity London College HospitalsLondonUK
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18
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Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett L, Paniagua-Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Sales AE, Wittmann DA. Correction: Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer. Implement Sci Commun 2023; 4:31. [PMID: 36941664 PMCID: PMC10026413 DOI: 10.1186/s43058-023-00411-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Megan V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly Dossett
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Alan Paniagua-Cruz
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | | | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
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19
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Stensland KD, Sales AE, Damschroder LJ, Skolarus TA. Correction: Applying implementation frameworks to the clinical trial context. Implement Sci Commun 2023; 4:27. [PMID: 36918958 PMCID: PMC10015771 DOI: 10.1186/s43058-023-00413-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Affiliation(s)
- Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA. .,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.,Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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20
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Caram MEV, Kumbier K, Burns J, Sparks JB, Tsao PA, Stensland KD, Washington SL, Hollenbeck BK, Shahinian V, Skolarus TA. Differential adoption of castration-resistant prostate cancer treatment across facilities in a national healthcare system. Cancer Med 2023; 12:6945-6955. [PMID: 36790037 PMCID: PMC10067072 DOI: 10.1002/cam4.5490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/15/2022] [Accepted: 11/17/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Over the past decade, abiraterone and enzalutamide have largely replaced ketoconazole as oral treatments for castration-resistant prostate cancer (CRPC). We investigated the differential adoption of abiraterone and enzalutamide across facilities in a national healthcare system to understand the impact a facility has on the receipt of these novel therapies. METHODS Using data from the VA Corporate Data Warehouse, we identified a cohort of men with CRPC who received the most common first-line therapies: abiraterone, enzalutamide, docetaxel, or ketoconazole between 2010 and 2017. We described variability in the adoption of abiraterone and enzalutamide across facilities by time period (2010-2013 or 2014-2017). We categorized facilities depending on the timing of adoption of abiraterone and enzalutamide relative to other facilities and described facility characteristics associated with early and late adoption. RESULTS We identified 4998 men treated with ketoconazole, docetaxel, abiraterone, or enzalutamide as first-line CRPC therapy between 2010 and 2017 at 125 national facilities. When limiting the cohort to oral therapies, most patients treated earlier in the study period (2010-2013) received ketoconazole. A dramatic shift was seen by the second half of the study period (2014-2017) with most men treated with first-line abiraterone (61%). Despite this shift and a new standard of care, some facilities persisted in the widespread use of ketoconazole in the later period, so-called late adopting facilities. After multivariable adjustment, patients who received treatment at a late adopting facility were more likely receiving care at a lower complexity, rural facility, with less urology and hematology/oncology workforce (all p < 0.01). CONCLUSION Many facilities persisted in their use of ketoconazole as first-line CRPC therapy, even when other facilities had adopted the new standard of care abiraterone and enzalutamide. Further work is needed to identify the effect of this late adoption on outcomes important to patients.
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Affiliation(s)
- Megan E. V. Caram
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Kyle Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Jennifer Burns
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Jordan B. Sparks
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | - Phoebe A. Tsao
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare SystemMichiganAnn ArborUSA
| | | | - Samuel L. Washington
- Department of UrologyUniversity of California San FranciscoCaliforniaSan FranciscoUSA
| | - Brent K. Hollenbeck
- Department of UrologyUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
| | - Vahakn Shahinian
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
- Department of UrologyUniversity of Michigan Medical SchoolMichiganAnn ArborUSA
| | - Ted A. Skolarus
- Department of UrologyUniversity of Chicago Pritzker School of MedicineIllinoisChicagoUSA
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21
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Zhu A, Berends JE, Daignault-Newton S, Kaye DR, Parker C, IglayReger H, Morgan TM, Weizer AZ, Kaffenberger SD, Herrel LA, Hafez K, Skolarus TA, Montgomery JS. Use of a physical activity monitor to track perioperative activity of radical cystectomy patients our first glimpse at what our patients are doing before and after surgery. Urol Oncol 2023; 41:206.e11-206.e19. [PMID: 36842878 DOI: 10.1016/j.urolonc.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/22/2023] [Accepted: 01/30/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE To optimize recovery after radical cystectomy (RC), providers stress the importance of ambulation and adequate rest. However, little is known about the activity and sleep habits of patients undergoing RC. Therefore, we utilized a wearable physical activity monitor (PAM) in the perioperative period to provide the first objective data on physical activity and sleep habits for RC patients. MATERIALS AND METHODS We prospectively identified patients ≥60 years old with planned RC. Participants completed a 4-week prehabilitation exercise program prior to surgery. They wore a PAM for 7-day intervals: at baseline, after prehabilitation, at postoperative day (POD) 30 and POD90. We tracked physical activity via metabolic equivalents (METs). METs were categorized by intensity: light (MET 1.5-<3), moderate (MET 3-<6), and vigorous (MET ≥6). We calculated daily step totals. We tracked hours slept and number of sleep awakenings. We correlated activity and sleep with self-reported quality of life (QOL). RESULTS Forty-two patients completed prehabilitation and RC. Moderate intensity exercise decreased at POD30 (61 minutes/d at baseline, 30 minutes/d at POD30, P = 0.005). Physical activity did not significantly differ for light or vigorous activity at any timepoint. RC did not significantly affect sleep. Sleep and physical activity were associated with mental and physical QOL, respectively. CONCLUSIONS This is the first study utilizing patient-worn monitors in RC to track physical activity and sleep. This study gives patients and providers a better understanding of postcystectomy recovery expectations. With these results in mind, interventions may be implemented to optimize activity and sleep in the perioperative period.
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Affiliation(s)
- Alex Zhu
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | | | | | - Deborah R Kaye
- Division of Urology, Department of Surgery, Duke University, Durham, NC
| | - Chrissy Parker
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI
| | - Heidi IglayReger
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI
| | - Todd M Morgan
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | - Alon Z Weizer
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | | | | | - Khaled Hafez
- Department of Urology, Michigan Medicine, Ann Arbor, MI
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22
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Wittmann D, Mehta A, McCaughan E, Faraday M, Duby A, Matthew A, Incrocci L, Burnett A, Nelson CJ, Elliott S, Koontz BF, Bober SL, McLeod D, Capogrosso P, Yap T, Higano C, Loeb S, Capellari E, Glodé M, Goltz H, Howell D, Kirby M, Bennett N, Trost L, Odiyo Ouma P, Wang R, Salter C, Skolarus TA, McPhail J, McPhail S, Brandon J, Northouse LL, Paich K, Pollack CE, Shifferd J, Erickson K, Mulhall JP. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022; 19:1655-1669. [PMID: 36192299 DOI: 10.1016/j.jsxm.2022.08.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/18/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strain their relationships. AIM We convened an international panel with the aim of developing guidelines that will inform clinicians, patients and partners about the impact of prostate cancer therapies (PCT) on patients' and partners' sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship. METHODS The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995-2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment, according to the nomenclature of the American Urological Association (AUA). Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR). OUTCOMES Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel. RESULTS The guidelines account for patients' cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side-effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship. CLINICAL IMPLICATIONS The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer. STRENGTHS & LIMITATIONS The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. Limitation is the variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries. CONCLUSION The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation and outline areas for future research. Wittmann D, Mehta A, McCaughan E, et al. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022;19:1655-1669.
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Affiliation(s)
- Daniela Wittmann
- Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - Akanksha Mehta
- Department of Urology, Emory University, Atlanta, GA, USA
| | - Eilis McCaughan
- In Memoriam, Ulster University School of Nursing, County Londonderry, Colraine, UK
| | | | - Ashley Duby
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Andrew Matthew
- Adult Psychiatry and Health System, Princess Margaret Cancer Center, Toronto, ON, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Arthur Burnett
- Department of Urology, Johns Hopkins University, Baltimore, MD, USA
| | - Christian J Nelson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stacy Elliott
- Departments of Psychiatry and Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | - Sharon L Bober
- Department of Psychiatry, Dana Farber Cancer Institute and Harvard University, Boston, MA, USA
| | - Deborah McLeod
- School of Nursing, NS Health Authority and Dalhousie University, Halifax, NS, Canada
| | - Paolo Capogrosso
- Department of Urology, Ciircolo & Fondazione Macchi Hospital, University of Insubria, Varese, Lombardy, Italy
| | - Tet Yap
- Department of Urology, Guys & St Thomas' Hospital, City of London, London, UK
| | - Celestia Higano
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Stacy Loeb
- Department of Urology at NYU Grossman School of Medicine, New York, NY, USA
| | - Emily Capellari
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Michael Glodé
- Department of Medical Oncology, University of Colorado Cancer Center, Aurora, CO, USA
| | - Heather Goltz
- School of Social Work, University of Houston-Downtown, Houston, TX, USA
| | - Doug Howell
- Patient with Lived Experience, Keaau, HI, USA
| | - Michael Kirby
- Faculty of the Health and Human Sciences, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Nelson Bennett
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Landon Trost
- Department of Urology, Brigham Young University, Provo, UT, USA; Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | | - Run Wang
- Department of Surgery-Urology, University of Texas McGovern Medical School, Houston, TX, USA; Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Carolyn Salter
- Department of Urology, Madigan Army Medical Center, Tacoma, WA, USA
| | - Ted A Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI, USA; VA Health Services Research & Development, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - John McPhail
- Patient and Partner with Lived Experience, Okemos, MI, USA
| | - Susan McPhail
- Patient and Partner with Lived Experience, Okemos, MI, USA
| | - Jan Brandon
- Partner with Lived Experience, Nashville, TN, USA
| | | | - Kellie Paich
- Clinical Quality and Survivorship, Movember Foundation, Culver City, CA, USA
| | - Craig E Pollack
- Department of Health Policy Management, Johns Hopkins University, Baltimore, MD, USA
| | - Jen Shifferd
- Department of Physical Therapy and Rehabilitation Medicine, Michigan Medicine Therapy Services, Ann Arbor, MI, USA
| | - Kim Erickson
- Department of Physical Therapy and Rehabilitation Medicine, Michigan Medicine Therapy Services, Ann Arbor, MI, USA
| | - John P Mulhall
- Department of Sexual and Reproductive Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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23
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Stensland KD, Sales AE, Damschroder LJ, Skolarus TA. Applying implementation frameworks to the clinical trial context. Implement Sci Commun 2022; 3:109. [PMID: 36217172 PMCID: PMC9552519 DOI: 10.1186/s43058-022-00355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Clinical trials advance science, benefit society, and provide optimal care to individuals with some conditions, such as cancer. However, clinical trials often fail to reach their endpoints, and low participant enrollment remains a critical problem with trial conduct. In these ways, clinical trials can be considered beneficial evidence-based practices suffering from poor implementation. Prior approaches to improving trials have had difficulties with reproducibility and limited impact, perhaps due to the lack of an underlying trial improvement framework. For these reasons, we propose adapting implementation science frameworks to the clinical trial context to improve the implementation of clinical trials. MAIN TEXT We adapted an outcomes framework (Proctor's Implementation Outcomes Framework) and a determinants framework (the Consolidated Framework for Implementation Research) to the trial context. We linked these frameworks to ERIC-based improvement strategies and present an inferential process model for identifying and selecting trial improvement strategies based on the Implementation Research Logic Model. We describe example applications of the framework components to the trial context and present a worked example of our model applied to a trial with poor enrollment. We then consider the implications of this approach on improving existing trials, the design of future trials, and assessing trial improvement interventions. Additionally, we consider the use of implementation science in the clinical trial context, and how clinical trials can be "test cases" for implementation research. CONCLUSIONS Clinical trials can be considered beneficial evidence-based interventions suffering from poor implementation. Adapting implementation science approaches to the clinical trial context can provide frameworks for contextual assessment, outcome measurement, targeted interventions, and a shared vocabulary for clinical trial improvement. Additionally, exploring implementation frameworks in the trial context can advance the science of implementation through both "test cases" and providing fertile ground for implementation intervention design and testing.
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Affiliation(s)
- Kristian D Stensland
- Dow Division of Health Services Research, Department of Urology, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA. .,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.,Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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24
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Hawley ST, Metreger T, Kim H, Skolarus TA. 12-month secondary outcomes of a prostate cancer survivor symptom self-management intervention. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
373 Background: Long term adverse symptoms following treatment for prostate cancer are prevalent and can negatively impact quality of life and increase healthcare seeking, even though many symptoms can be effectively self-managed. There remains a need for tools to support long term survivors to feel confident in their ability to self-manage their symptoms, potentially translating to more efficient health care utilization. Methods: We conducted a RCT of an automated tailored self-management support intervention (vs. newsletter) for long term (> 1 year) Veteran survivors of prostate cancer recruited from 4/2015-2/2017 across four VA sites. Participants were randomized (278 per arm) and assessed via survey at 5 months and 12 months post enrollment. The intervention delivered tailored information regarding symptoms for urinary, sexual, bowel and general health over 3 months, allowing participants to choose focus areas. At 12 months, we assessed secondary trial outcomes; participants’ reports of use of services relative to their symptoms (urinary, bowel, sexual, general health) and their confidence in symptom self-management (scale from 5-15). We also assessed use of procedures and medications related to each symptom area via medical charts. We tested differences in reported and documented service use between arms using T-tests and Chi-square tests. We further assessed participants engagement in components of the intervention. Results: Of those randomized, 81.7% completed the 12-month survey assessment (N = 226 Intervention and N = 228 Control). The average age was 66.7, 28% were Black, and 49% were high school graduates or less. Participants in the intervention arm reported greater confidence in symptom self-management than controls (Mean: 13.5 vs. 12.9; P = 0.01). Intervention participants reported less often using services related to urinary (43.9% vs. 56.0%, P = 0.03) and sexual (42.3% vs. 57.6%, P = 0.04) health over the prior 7 months. Review of intervention paradata found that urinary and sexual health were the topics most frequently engaged with among intervention subjects. No significant differences in medical chart documented procedures related to symptom areas were found. Conclusions: This secondary trial analysis found that 12 months post enrollment, Veterans who engaged with a tailored self-management intervention were more confident in their ability to self-manage their symptoms. The associated finding of fewer visits for the most commonly chosen areas for symptom self-management suggests that such an intervention may hold promise for helping long term survivors to effectively self-manage adverse symptoms. Clinical trial information: NCT01900561.
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Affiliation(s)
- Sarah T. Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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25
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Stensland KD, Damschroder LJ, Sales AE, Schott AF, Skolarus TA. Envisioning clinical trials as complex interventions. Cancer 2022; 128:3145-3151. [PMID: 35766902 PMCID: PMC9378578 DOI: 10.1002/cncr.34357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
Clinical trials are critical components of modern health care and infrastructure. Trials benefit society through scientific advancement and individual patients through trial participation. In fact, billions of dollars are spent annually in support of these benefits. Despite the massive investments, clinical trials often fail to accomplish their primary aims and trial enrollment rates remain low. Prior efforts to improve trial conduct and enrollment have had limited success, perhaps due to oversimplification of the complex, multilevel nature of trials. For these reasons, the authors propose applying implementation science to the clinical trials context. In this commentary, the authors posit clinical trials as complex, multilevel evidence-based interventions with significant societal and individual benefits yet with persistent gaps in implementation. An application of implementation science concepts to the clinical trials context as means to build common vocabulary and establish a platform for applying implementation science and practice to improve clinical trial conduct is introduced. Applying implementation science to the clinical trials context can augment improvement efforts and build capacity for better and more efficient evidence-based care for all patients and trial stakeholders throughout the clinical trials enterprise.
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Affiliation(s)
- Kristian D. Stensland
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
| | - Laura J. Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Anne E. Sales
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Sinclair School of Nursing, University of Missouri and Department of Family and Community MedicineUniversity of MissouriColumbiaMissouriUSA
| | - Anne F. Schott
- University of Michigan Rogel Cancer CenterAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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26
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Radhakrishnan A, Wallner LP, Skolarus TA, George AK, Rosenberg BH, Abrahamse P, Hawley ST. Exploring Variation in the Receipt of Recommended Active Surveillance for Men with Favorable-Risk Prostate Cancer. J Urol 2022; 208:600-608. [PMID: 35522191 PMCID: PMC9378546 DOI: 10.1097/ju.0000000000002734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/23/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Men on active surveillance for favorable-risk prostate cancer do not receive all the recommended testing. Reasons for variation in receipt are unknown. MATERIALS AND METHODS We combined prospective registry data from the Michigan Urological Surgery Improvement Collaborative, a collaborative of 46 academic and community urology practices across Michigan, with insurance claims from 2014 to 2018 for men on active surveillance for favorable-risk prostate cancer. We defined receipt of recommended surveillance according to the collaborative's low-intensity criteria as: annual prostate specific antigen testing and either magnetic resonance imaging or prostate biopsy every 3 years. We assessed receipt of recommended surveillance among men with ≥36 months of followup (246). We conducted multilevel analyses to examine the influence of the urologist, urologist and primary care provider visits, and patient demographic and clinical factors on variation in receipt. RESULTS During 3 years of active surveillance, just over half of men (56.5%) received all recommended surveillance testing (69.9% annual prostate specific antigen testing, 72.8% magnetic resonance imaging/biopsy). We found 19% of the variation in receipt was attributed to individual urologists. While increasing provider visits were not significantly associated with receipt, older men were less likely to receive magnetic resonance imaging/biopsy (≥75 vs <55 years, adjusted odds ratio 0.07; 95% confidence interval 0.01-0.81). CONCLUSIONS Nearly half of men on active surveillance for favorable-risk prostate cancer did not receive all recommended surveillance. While urologists substantially influenced receipt of recommended testing, exploring how to leverage patients and their visits with their primary care providers to positively influence receipt appears warranted.
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Affiliation(s)
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | - Ted A Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Arvin K George
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Bradley H Rosenberg
- Department of Urology, Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Paul Abrahamse
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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27
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MacLennan S, Duncan E, Skolarus TA, Roobol MJ, Kasivisvanathan V, Gallagher K, Gandaglia G, Sakalis V, Smith EJ, Plass K, Ribal MJ, N'Dow J, Briganti A. Improving Guideline Adherence in Urology. Eur Urol Focus 2022; 8:1545-1552. [PMID: 34702647 DOI: 10.1016/j.euf.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/24/2021] [Accepted: 10/05/2021] [Indexed: 01/25/2023]
Abstract
CONTEXT Clinical practice guidelines (CPGs) distil an evidence base into recommendations. CPG adherence is associated with better patient outcomes. However, preparation and dissemination of CPGs are a costly task involving multiple skilled personnel. Furthermore, dissemination alone does not ensure CPG adherence. Reasons for nonadherence are often complex, but understanding practice variations and reasons for nonadherence is key to improving CPG adherence and harmonising clinically appropriate and cost-effective care. OBJECTIVE To overview approaches to improving guideline adherence, to provide urology-specific examples of knowledge-practice gaps, and to highlight potential solutions informed by implementation science. EVIDENCE ACQUISITION Three common approaches to implementation science (the Knowledge-To-Action framework, the Consolidated Framework for Implementation Research, and the Behaviour Change Wheel), are summarised. EVIDENCE SYNTHESIS Three implementation problems in urology are illustrated: underuse of single instillation of intravesical chemotherapy in non-muscle-invasive bladder cancer, overuse of androgen deprivation therapy in localised prostate cancer, and guideline-discordant imaging in prostate cancer. Research using implementation science approaches to address these implementation problems is discussed. CONCLUSIONS Urologists, patients, health care providers, funders, and other key stakeholders must commit to reliably capturing and reporting data on patient outcomes, practice variations, guideline adherence, and the impact of adherence on outcomes. Leverage of implementation science frameworks is a sound next step towards improving guideline adherence and the associated benefits of evidence-based care. PATIENT SUMMARY Clinical practice guideline documents are created by expert panels. These documents provide overviews of the evidence for the tests and treatments used in patient care. They also provide recommendations and it is expected that in most circumstances clinicians will follow these recommendations. Sometimes, health care professionals cannot or do not follow these recommendations and it is not always clear why. In this review article we look at some examples of research approaches to addressing this problem of nonadherence and we provide some examples specific to urology.
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Affiliation(s)
- Steven MacLennan
- Academic Urology Unit, Institute of Applied Health Sciences, The University of Aberdeen, Aberdeen, UK; European Association of Urology Guidelines Office and Methodology Committee, Arnhem, The Netherlands.
| | - Eilidh Duncan
- Health Services Research Unit, Institute of Applied Health Sciences, The University of Aberdeen, Aberdeen, UK
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA; Veterans Affairs Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Veeru Kasivisvanathan
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Kevin Gallagher
- Department of Urology, Western General Hospital, Edinburgh, UK
| | - Giorgio Gandaglia
- Department of Urology, University Vita e Salute-San Raffaele, Milan, Italy
| | - Vasileios Sakalis
- Department of Urology, General Hospital Agios Pavlos, Thessaloniki, Greece
| | - Emma Jane Smith
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Karin Plass
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Maria J Ribal
- European Association of Urology Guidelines Office, Arnhem, The Netherlands; Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - James N'Dow
- Academic Urology Unit, Institute of Applied Health Sciences, The University of Aberdeen, Aberdeen, UK; European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Alberto Briganti
- Department of Urology, University Vita e Salute-San Raffaele, Milan, Italy; European Association of Urology Guidelines Office, Arnhem, The Netherlands
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Stensland KD, Richesson RL, Vince RA, Skolarus TA, Sales AE. Evolving a national clinical trials learning health system. Learn Health Syst 2022; 7:e10327. [PMID: 37066100 PMCID: PMC10091198 DOI: 10.1002/lrh2.10327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/26/2022] [Accepted: 06/28/2022] [Indexed: 11/07/2022] Open
Abstract
Clinical trials generate key evidence to inform decision making, and also benefit participants directly. However, clinical trials frequently fail, often struggle to enroll participants, and are expensive. Part of the problem with trial conduct may be the disconnected nature of clinical trials, preventing rapid data sharing, generation of insights and targeted improvement interventions, and identification of knowledge gaps. In other areas of healthcare, a learning health system (LHS) has been proposed as a model to facilitate continuous learning and improvement. We propose that an LHS approach could greatly benefit clinical trials, allowing for continuous improvements to trial conduct and efficiency. A robust trial data sharing system, continuous analysis of trial enrollment and other success metrics, and development of targeted trial improvement interventions are potentially key components of a Trials LHS reflecting the learning cycle and allowing for continuous trial improvement. Through the development and use of a Trials LHS, clinical trials could be treated as a system, producing benefits to patients, advancing care, and decreasing costs for stakeholders.
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Affiliation(s)
| | - Rachel L. Richesson
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
| | - Randy A. Vince
- Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Anne E. Sales
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Sinclair School of NursingUniversity of MissouriColumbiaMissouriUSA
- Department of Family and Community MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
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Stensland KD, Caram MV, Burns JA, Sparks JB, Shin C, Zaslavsky A, Hollenbeck BK, Tsodikov A, Skolarus TA. Recurrence, metastasis, and survival after radical prostatectomy in the era of advanced treatments. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5090 Background: Accurate survival estimates after prostatectomy are critical for patient counseling, treatment decisions, and trial design. Prior prostate cancer natural history studies may not reflect contemporary outcomes and often lack key endpoints (e.g. incident metastases). For these reasons, we explored population-based recurrence and survival following radical prostatectomy. Methods: We conducted a retrospective study of men with localized prostate cancer treated with radical prostatectomy from 2005-2015 with follow up through 2019 in the Veterans Health Administration. We excluded men with adjuvant radiation or hormonal therapy and defined biochemical recurrence (BCR) as a PSA ≥0.2 ng/mL. We used a validated natural language processing encoded dataset to identify incident metastatic disease. We then estimated actuarial time from surgery to BCR, BCR to metastatic disease, and metastatic disease to death using Kaplan-Meier methods. Results: Of 22,033 men post-prostatectomy, 5,963 (27%) developed BCR, with 5- and 10-year BCR estimates of 21% and 29% (Table). Of 5,963 men with BCR, 678 (11%) developed metastasis, with 5- and 10-year metastasis-free survival from time of BCR of 91% and 77%. Of these 678 men with metastases, 235 died (35%), with 5- and 10-year overall survival of 61% and 47%. Median actuarial overall survival from incident metastatic disease was 8.8 years. Conclusions: On average, we found a man undergoing radical prostatectomy for localized prostate cancer can expect about a 1 in 4 chance of biochemical recurrence. Of men with BCR, we identified a 1 in 10 chance of developing metastases, surviving nearly 9 years after incident metastasis. Both metastasis-free survival after biochemical recurrence and overall survival after developing metastasis appear to have lengthened consistent with a long natural history after prostate cancer surgery. Novel advanced prostate cancer treatments may help explain these findings, though their optimal use warrants further study especially as advanced imaging techniques to characterize recurrence increase. [Table: see text]
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Affiliation(s)
- Kristian D. Stensland
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Megan Veresh Caram
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer A. Burns
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B. Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Chris Shin
- University of Michigan School of Public Health, Department of Biostatistics, Ann Arbor, MI
| | | | - Brent K. Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Alexander Tsodikov
- University of Michigan School of Public Health, Department of Biostatistics, Ann Arbor, MI
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Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett LA, Larkin A, Paniagua Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Wittmann DA, Deolankar V, Sriram S. Unpacking low-value castration practices using behavior specification to guide de-implementation in prostate cancer care. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e17055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17055 Background: Many men with prostate cancer will be exposed to ADT at some point during cancer survivorship. Unfortunately, ADT overuse in low-value scenarios is not uncommon (e.g., monotherapy in localized prostate cancer, biochemically-recurrent non-metastatic disease) resulting in more harms than benefits. We conducted an innovative survey study to unpack ADT overuse to inform behavior change and de-implementation strategies. Methods: Our survey used the Theoretical Domains Framework (TDF), and the Capability, Opportunity, Motivation – Behavior (COM-B) Model. The survey was fielded to the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on their likelihood of stopping ADT monotherapy in the case of a localized prostate cancer patient presenting to their office (yes/probably yes, probably no/no), and characterized Likert scale responses to 7 COM-B statements. We used multivariable logistic regression to identify associations between stopping ADT and COM-B responses across a dichotomized Likert scale of “strongly disagree/disagree/neutral” and “agree/strongly agree.”. Results: Our survey was completed by 84 respondents (13% response rate), with 27% indicating ‘probably no’/‘no’ to stopping low-value ADT monotherapy in the case of a localized prostate cancer patient presenting to their office. Our multivariable model identified 2 COM-B statements significantly associated with lower likelihood of stopping low-value ADT. Conclusions: Using an innovative, behavioral theory-informed survey, we identified that providers less likely to stop low-value ADT had greater concern about patient worry and were more interested in providing ADT recommendations consistent with peers, informing de-implementation strategy selection. Clinical trial information: MCT03579680. [Table: see text]
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Affiliation(s)
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B. Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Megan Veresh Caram
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | | | - Angela Larkin
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Danil V. Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY
| | - John T. Leppert
- Surgical Service, Veteran’s Affairs Palo Alto Health Care System, Palo Alto, CA
| | | | - Kristian D. Stensland
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Brent K. Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Vahakn Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Daniela A. Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI
| | - Varad Deolankar
- University of Michigan Ross School of Business, Ann Arbor, MI
| | - S. Sriram
- University of Michigan Ross School of Business, Ann Arbor, MI
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Wittmann D, Mehta A, Bober SL, Zhu Z, Daignault-Newton S, Dunn RL, Braun TM, Carter C, Duby A, Northouse LL, Koontz BF, Glodé LM, Brandon J, Bangs R, McPhail J, McPhail S, Arab L, Paich K, Skolarus TA, An LC, Nelson CJ, Saigal CS, Chen RC, Mulhall JP, Hawley ST, Hearn JWD, Spratt DE, Pollack CE. TrueNTH Sexual Recovery Intervention for couples coping with prostate cancer: Randomized controlled trial results. Cancer 2022; 128:1513-1522. [PMID: 34985771 DOI: 10.1002/cncr.34076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite significant sexual dysfunction and distress after localized prostate cancer treatment, patients typically receive only physiologic erectile dysfunction management. The authors performed a randomized controlled trial of an online intervention supporting couples' posttreatment recovery of sexual intimacy. METHODS Patients treated with surgery, radiation, or combined radiation and androgen deprivation therapy who had partners were recruited and randomized to an online intervention or a control group. The intervention, tailored to treatment type and sexual orientation, comprised 6 modules addressing expectations for sexual and emotional sequelae of treatment, rehabilitation, and guidance toward sexual intimacy recovery. Couples, recruited from 6 sites nationally, completed validated measures at the baseline and 3 and 6 months after treatment. Primary outcome group differences were assessed with t tests for individual outcomes. RESULTS Among 142 randomized couples, 105 patients (mostly surgery) and 87 partners completed the 6-month survey; this reflected challenges with recruitment and attrition. There were no differences between the intervention and control arms in Patient-Reported Outcomes Measurement Information System Global Satisfaction With Sex Life scores 6 months after treatment (the primary outcome). Three months after treatment, intervention patients and partners reported more engagement in penetrative and nonpenetrative sexual activities than controls. More than 73% of the intervention participants reported high or moderate satisfaction with module content; more than 85% would recommend the intervention to other couples. CONCLUSIONS Online psychosexual support for couples can help couples to connect and experience sexual pleasure early after treatment despite patients' sexual dysfunction. Participants' high endorsement of the intervention reflects the importance of sexual health support to couples after prostate cancer treatment. LAY SUMMARY This study tested a web-based program supporting couples' sexual recovery of sexual intimacy after prostate cancer treatment. One hundred forty-two couples were recruited and randomly assigned to the program (n = 60) or to a control group (n = 82). The program did not result in improvements in participants' satisfaction with their sex life 6 months after treatment, but couples in the intervention group engaged in sexual activity sooner after treatment than couples in the control group. Couples evaluated the program positively and would recommend it to others facing prostate cancer treatment.
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Affiliation(s)
- Daniela Wittmann
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Akanksha Mehta
- Department of Urology, Emory University, Atlanta, Georgia
| | - Sharon L Bober
- Sexual Health Program, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Psychiatry, Harvard University, Boston, Massachusetts
| | - Ziwei Zhu
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Rodney L Dunn
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Thomas M Braun
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Caroline Carter
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Ashley Duby
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Bridget F Koontz
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - L Michael Glodé
- School of Medicine, Medical Oncology, University of Colorado, Aurora, Colorado
| | | | | | | | | | - Lenore Arab
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | | | - Ted A Skolarus
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- VA Health Services Research & Development, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lawrence C An
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Christian J Nelson
- Male Sexual and Reproductive Medicine Program, Memorial Sloan Kettering, New York, New York
- Psychiatry Service, New York, New York
| | - Christopher S Saigal
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Ronald C Chen
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - John P Mulhall
- Center for Sexual and Reproductive Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarah T Hawley
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Jason W D Hearn
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Daniel E Spratt
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Craig E Pollack
- Department of Health Policy and Management I School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Stensland KD, Devasia T, Caram M, Chapman C, Zaslavsky A, Morgan TM, Hollenbeck BK, Sparks J, Burns J, Vedapudi V, Duchesne GM, Tsodikov A, Skolarus TA. Better Understanding the Timing of Androgen Deprivation (TOAD) Trial Outcomes: Impacts of Prior ADT. JNCI Cancer Spectr 2022; 6:6555004. [PMID: 35616109 PMCID: PMC9134272 DOI: 10.1093/jncics/pkac025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 01/03/2022] [Accepted: 02/02/2022] [Indexed: 11/12/2022] Open
Abstract
Background The Timing Of Androgen Deprivation (TOAD) trial found an overall survival benefit for immediate vs delayed androgen deprivation therapy (ADT) for prostate-specific antigen (PSA)–relapsed or noncurable prostate cancer. However, broad eligibility criteria allowed entry of a heterogeneous participant group, including those with prior ADT exposure, raising concerns about subsequent androgen sensitivity. For these reasons, we completed previously specified subgroup analyses to assess if prior ADT was associated with ADT timing efficacy after PSA relapse. Methods We examined TOAD trial patient-level data for participants with PSA relapse after local therapy. We performed Kaplan-Meier analyses for overall survival stratified by prior ADT and randomized treatment arm (immediate or delayed ADT). We compared group characteristics using Mann-Whitney U and Fisher exact tests. All hypothesis tests were 2-sided. Results We identified 261 patients with PSA relapse, 125 of whom received prior ADT. Patients with prior ADT had higher PSA at presentation (12.1 vs 9.0 ng/mL; P < .001), more cT3 disease (38.4% vs 25.0%; P = .007), and more likely received radiotherapy as local treatment (80.0% vs 47.8%; P < .001) but were otherwise similar to patients without prior ADT exposure. Within this prior ADT group, those who received immediate ADT (n = 56) had improved overall survival compared with those who received delayed ADT (n = 69; P = .02). This benefit was not observed in the group with no prior ADT (P = .98). Conclusions The survival benefit demonstrated in the TOAD trial may be driven by patients who received ADT prior to trial entry. We provide possible explanations for this finding with implications for treatment of PSA-relapsed prostate cancer and future study planning.
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Affiliation(s)
- Kristian D Stensland
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Theresa Devasia
- Department of Biostatistics, University of Michigan School of Public Health,Ann Arbor, MI, USA
| | - Megan Caram
- Department of Medicine, Division of Oncology, University of Michigan, Ann Arbor, MI, USA
- Health Services Research & Development Center for Clinical Management Research, Ann, Arbor, VA, Healthcare System, Ann Arbor, MI, USA
| | - Christina Chapman
- Health Services Research & Development Center for Clinical Management Research, Ann, Arbor, VA, Healthcare System, Ann Arbor, MI, USA
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Alexander Zaslavsky
- Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Todd M Morgan
- Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Jordan Sparks
- Health Services Research & Development Center for Clinical Management Research, Ann, Arbor, VA, Healthcare System, Ann Arbor, MI, USA
| | - Jennifer Burns
- Health Services Research & Development Center for Clinical Management Research, Ann, Arbor, VA, Healthcare System, Ann Arbor, MI, USA
| | - Varsha Vedapudi
- Health Services Research & Development Center for Clinical Management Research, Ann, Arbor, VA, Healthcare System, Ann Arbor, MI, USA
| | - Gillian M Duchesne
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
| | - Alexander Tsodikov
- Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, MI, USA
- Health Services Research & Development Center for Clinical Management Research, Ann, Arbor, VA, Healthcare System, Ann Arbor, MI, USA
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Lai LY, Oerline MK, Kaufman SR, Herrel LA, Skolarus TA, Dusetzina SB, Ellimoottil C, Shahinian VB, Hollenbeck BK, Caram MEV. Promotional Payments to Medical Oncologists and Urologists and Prescriptions for Abiraterone and Enzalutamide. Urology 2022; 161:50-58. [PMID: 34861316 PMCID: PMC8940668 DOI: 10.1016/j.urology.2021.10.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/04/2021] [Accepted: 10/04/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To understand the influence of drug manufacturers on the prescribing patterns of medical oncologists and urologists, we examined the relationship between promotional payments from the manufacturers of abiraterone and enzalutamide and prescriptions for either drug by medical oncologists and urologists. METHODS Promotional payments for abiraterone or enzalutamide made to medical oncologists and urologists between January 2014 and December 2017 reported through the Open Payments Program were categorized as $0, $1$999, and $1000 or more. Prescriptions filled between January 2013 and December 2017 were identified in the Medicare Part D File. Associations between promotional payments and prescribing were assessed using generalized linear models. RESULTS From 2013 through 2017, the number of medical oncologists and urologists prescribing abiraterone or enzalutamide increased by 38% - 298%, respectively. The odds of prescribing among medical oncologists receiving $1--$999 and those receiving $1,000 or more were 1.69 (95%CI:1.59--1.79) and 2.61 (95% CI: 2.14--3.18) times that of medical oncologists receiving no payments. Among urologists receiving $1--$999 and those receiving $1,000 or more, the odds of prescribing were 4.04 (95%CI: 3.59--4.54) and 13.57 (95%CI: 9.69--19.0) times that of urologists receiving no payments. CONCLUSION Increasing promotional payments were associated with prescribing among medical oncologists and urologists, with a stronger relationship evident for urologists. Prescribing patterns for abiraterone and enzalutamide, particularly among urologists, may be influenced by payments from drug manufacturers.
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Affiliation(s)
- Lillian Y Lai
- Departments of Urology, University of Michigan, Ann Arbor, MI.
| | - Mary K Oerline
- Departments of Urology, University of Michigan, Ann Arbor, MI
| | | | | | - Ted A Skolarus
- Departments of Urology, University of Michigan, Ann Arbor, MI; Veterans Affairs Health Services Research & Development, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN; Vanderbilt-Ingram Cancer Center, Nashville, TN
| | | | - Vahakn B Shahinian
- Departments of Urology, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Megan E V Caram
- Veterans Affairs Health Services Research & Development, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Caram MV, Kumbier K, Tsao PA, Burns JA, Sparks J, Bauman J, Stensland K, Hollenbeck BK, Shahinian VB, Skolarus TA. The changing landscape of treatment and survival for men with castration-resistant prostate cancer in the era of novel treatments. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
67 Background: Several therapies for men with castration-resistant prostate cancer (CRPC) have become available since 2010 with the hope of prolonging survival for those at the end stages of their disease. Little is known about the survival of men who receive novel therapies in the real world and the disease burden of patients initiating treatment for CRPC between 2010 and 2017. Methods: Using the Veterans Health Affairs Corporate Data Warehouse, we identified Veterans with CRPC who received first-line therapy for castration-resistant disease between 2010-2017. Therapies included ketoconazole, docetaxel, abiraterone, and enzalutamide since > 99% of patients treated for CRPC received one of these therapies first-line for CRPC. We used a Cox model to calculate the overall survival of patients from time of first CRPC treatment for each year. We then adjusted for patient and disease characteristics, such as starting PSA level, and prognostic group at the start of treatment based on hemoglobin, alkaline phosphatase, and albumin levels. Results: In a cohort of 4,998 men started on treatment for CRPC between 2010-2017, survival from start of first-line treatment gradually increased between 2010-2017. In 2010, when 38% of men received docetaxel first-line and 62% ketoconazole, the probability of surviving at least one year from start of first-line therapy was 64%. In 2017, when the landscape of first-line treatment had changed (49% abiraterone, 9% docetaxel, 41% enzalutamide, 1% ketoconazole) one-year survival from start of first therapy improved to 72%. The unadjusted hazard ratio (HR) for an additional calendar year was 0.93 (95% confidence interval [CI], 0.91-0.95). Men started on first-line CRPC therapy in 2010 had worse prognostic labs at the start of therapy, suggesting worse disease, and had a higher PSA value at the start of therapy compared to those started on CRPC therapy in 2017 (median PSA 55.1 in 2010 vs 27.8 in 2017, p-value < 0.01). When adjusting for disease characteristics, the improvement in survival we saw between 2010 and 2017 was diminished with adjusted HR for an additional calendar year of 0.97 (95% CI, 0.94-1.00). Conclusions: With the development of novel therapies, the survival of patients with similar disease burden should gradually improve over time. Although we did see a modest improvement in survival between 2010-2017, this improvement was mitigated when adjusting for disease severity, suggesting that some of the improvement in survival may be affected by a lead-time bias—treating patients earlier in their CRPC.
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Affiliation(s)
- Megan Veresh Caram
- Department of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | - Kyle Kumbier
- Ann Arbor Veterans Health Administration, Ann Arbor, MI
| | - Phoebe A. Tsao
- Department of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | | | - Jordan Sparks
- Ann Arbor Veterans Health Administration, Ann Arbor, MI
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Parry MG, Nossiter J, Morris M, Sujenthiran A, Skolarus TA, Berry B, Nathan A, Cathcart P, Aggarwal A, van der Meulen J, Trinh QD, Payne H, Clarke NW. Comparison of the treatment of men with prostate cancer between the US and England: an international population-based study. Prostate Cancer Prostatic Dis 2022:10.1038/s41391-021-00482-6. [PMID: 35001083 DOI: 10.1038/s41391-021-00482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The treatment of prostate cancer varies between the United States (US) and England, however this has not been well characterised using recent data. We therefore investigated the extent of the differences between US and English patients with respect to initial treatment. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) database to identify men diagnosed with prostate cancer in the US and the treatments they received. We also used the National Prostate Cancer Audit (NPCA) database for the same purposes among men diagnosed with prostate cancer in England. Next, we used multivariable regression to estimate the adjusted risk ratio (aRR) of receiving radical local treatment for men with non-metastatic prostate cancer according to the country of diagnosis (US vs. England). The five-tiered Cambridge Prognostic Group (CPG) classification was included as an interaction term. RESULTS We identified 109,697 patients from the SEER database, and 74,393 patients from the NPCA database, who were newly diagnosed with non-metastatic prostate cancer between April 1st 2014 and December 31st 2016 with sufficient information for risk stratification according to the CPG classification. Men in the US were more likely to receive radical local treatment across all prognostic groups compared to men in England (% radical treatment US vs. England, CPG1: 38.1% vs. 14.3% - aRR 2.57, 95% CI 2.47-2.68; CPG2: 68.6% vs. 52.6% - aRR 1.27, 95% CI 1.25-1.29; CPG3: 76.7% vs. 67.1% - aRR 1.12, 95% CI 1.10-1.13; CPG4: 82.6% vs. 72.4% - aRR 1.09, 95% CI 1.08-1.10; CPG5: 78.2% vs. 71.7% - aRR 1.06, 95% CI 1.04-1.07) CONCLUSIONS: Treatment rates were higher in the US compared to England raising potential over-treatment concerns for low-risk disease (CPG1) in the US and under-treatment of clinically significant disease (CPG3-5) in England.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK. .,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.
| | - Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Flatiron, London, UK
| | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Arjun Nathan
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,University College London, London, UK
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Quoc-Dien Trinh
- Harvard Medical School, Boston, USA.,Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK.,Department of Urology, Salford Royal NHS Foundation Trust, Salford, UK
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Wittmann D, Varlamos C, Rodriguez-Galano N, Day L, Grube G, Shifferd J, Erickson K, Duby A, Morgan TM, Hollenbeck BK, Skolarus TA, Salami SS, Kaffenberger SD, Montie JE. Developing a Patient-Centered Model of Prostate Cancer Care: Patient Satisfaction With a Survivorship Program Embedded in Urologic-Oncologic Care. Urology 2021; 160:161-167. [PMID: 34896123 DOI: 10.1016/j.urology.2021.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/10/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate patients' and partners' satisfaction with a prostate cancer survivorship program embedded in urologic-oncologic care. As a part of quality improvement activity, we developed a patient and partner-centered, biopsychosocial support program for men and partners coping with the urinary and sexual side-effects of surgical treatment for prostate cancer. The program became a part of usual care for all prostate cancer patients. METHODS Patients who saw both an advanced practice provider and a sex therapist between August 1, 2018 and July 31, 2019 were eligible. Surveys packets were sent to 146 patients with surveys included for partners (N = 292). We used descriptive statistics to characterize participant responses. RESULTS Responses were received from 88 patients and 70 partners (56% response rate for the group). Patients and partners reported very high or fairly high satisfaction with the rehabilitation activities of the program (86-97% and 90%-100%, respectively); 91% of patients and 84% of partners thought having pre-operative education and post-operative rehabilitation was a good or fairly good idea; 83% of patients and 79% of partners would very much or somewhat recommend the program to a friend who was considering surgical treatment for prostate cancer. CONCLUSION Embedding a patient and partner-centered prostate cancer survivorship support program in oncologic care can positively impact patients' and partners' engagement in and satisfaction with post-operative rehabilitation.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - T A Skolarus
- University of Michigan; Center for Clinical Management Research, VA Ann Arbor Healthcare System
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Parry MG, Skolarus TA, Nossiter J, Sujenthiran A, Morris M, Cowling TE, Berry B, Aggarwal A, Payne H, Cathcart P, Clarke NW, van der Meulen J. Urinary incontinence and use of incontinence surgery after radical prostatectomy: a national study using patient-reported outcomes. BJU Int 2021; 130:84-91. [PMID: 34846770 DOI: 10.1111/bju.15663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate whether patient-reported urinary incontinence and bother scores after radical prostatectomy result in subsequent intervention with incontinence surgery. METHODS Men diagnosed with prostate cancer in the English National Health Service between April 2014 and January 2016 were identified. Administrative data were used to identify men who had undergone a radical prostatectomy and those who subsequently underwent a urinary incontinence procedure. The National Prostate Cancer Audit database was used to identify men who had also completed a post-treatment survey. These surveys included the Expanded Prostate Cancer Composite Index (EPIC-26). The frequency of subsequent incontinence procedures, within 6 months of the survey, was explored according to EPIC-26 urinary incontinence scores. The relationship between "good" (≥75) or "bad" (≤25) EPIC-26 urinary incontinence scores and perceptions of urinary bother was also explored (responses ranging from 'no problem' to 'big problem' with respect to their urinary function). RESULTS We identified 11,290 men who had undergone a radical prostatectomy. The 3-year cumulative incidence of incontinence surgery was 2.5%. After exclusions, we identified 5,165 men who had also completed a post-treatment survey after a median time of 19 months (response rate 74%). 481 men (9.3%) reported a "bad" urinary incontinence score and 207 men (4.0%) also reported that they had a big problem with their urinary function. 47 men went on to have incontinence surgery within 6 months of survey completion (0.9%), of whom 93.6% had a "bad" urinary incontinence score. Of the 71 men with the worst urinary incontinence score (zero), only 11 men (15.5%) subsequently had incontinence surgery. CONCLUSION In England, there is a significant number of men living with severe, bothersome urinary incontinence following radical prostatectomy, and an unmet clinical need for incontinence surgery. The systematic collection of patient-reported outcomes could be used to identify men who may benefit from incontinence surgery.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, USA.,Flatiron, UK
| | - Melanie Morris
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | | | - Brendan Berry
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Ajay Aggarwal
- Department of Radiotherapy, NHS Foundation Trust, Guy's & St Thomas, UK.,Department of Cancer Epidemiology, KCL, Population & Global Health, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Paul Cathcart
- Department of Urology, NHS Foundation Trust, Guy's & St Thomas, UK
| | - Noel W Clarke
- Department of Urology, Salford Royal NHS Foundation Trusts, The Christie &, UK
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Lai LY, Shahinian VB, Oerline MK, Kaufman SR, Skolarus TA, Caram MEV, Hollenbeck BK. Understanding Active Surveillance for Prostate Cancer. JCO Oncol Pract 2021; 17:e1678-e1687. [PMID: 33830822 PMCID: PMC9810129 DOI: 10.1200/op.20.00929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To assess how active surveillance for prostate cancer is apportioned across specialties and how testing patterns and transition to treatment vary by specialty. METHODS We used a 20% national sample of Medicare claims to identify men diagnosed with prostate cancer from 2010 through 2016 initiating surveillance (N = 13,048). Patients were assigned to the physician responsible for the bulk of surveillance care based on billing patterns. Freedom from treatment was assessed by specialty of the responsible physician (urology, radiation oncology, medical oncology, and primary care). Multinomial logistic regression models were used to examine associations between specialty and treatment patterns. RESULTS Urologists were responsible for surveillance in 93.7% of patients in 2010 and 96.2% of patients in 2016 (P for trend = .01). Testing patterns varied by specialty. For example, patients of medical oncologists had more frequent prostate-specific antigen testing compared with patients of urologists (1.85 v 2.39 tests per year, respectively; P < .01). Three years after diagnosis, a significantly smaller proportion of patients managed by radiation oncologists (64.3%) remained on surveillance compared with patients managed by other physicians (75.8%-79.5%; P < .01). Although radiation was the most common treatment among all men who transitioned to treatment, a disproportionate percentage of patients followed by radiation oncologists (28.9%) ultimately underwent radiation compared with patients followed by other physicians (15.1%-15.4%; P < .01). CONCLUSION Nontrivial percentages of patients on active surveillance are managed by physicians outside of urology. Given the interspecialty variations observed, efforts to strengthen the evidence underlying surveillance pathways and to engage other specialties in guideline development are needed.
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Affiliation(s)
- Lillian Y. Lai
- Department of Urology, University of Michigan, Ann Arbor, MI,Lillian Y. Lai, MD, Dow Division for Health Services Research, Department of Urology, University of Michigan, 2800 Plymouth Rd, Bldg 16, Ann Arbor, MI 48109-2800; e-mail:
| | - Vahakn B. Shahinian
- Department of Urology, University of Michigan, Ann Arbor, MI,Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Mary K. Oerline
- Department of Urology, University of Michigan, Ann Arbor, MI
| | | | - Ted A. Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI,Veterans Affairs Ann Arbor Healthcare System, HSR&D, Center for Clinical Management Research, Ann Arbor, MI
| | - Megan E. V. Caram
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI,Veterans Affairs Ann Arbor Healthcare System, HSR&D, Center for Clinical Management Research, Ann Arbor, MI
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Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett L, Paniagua-Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Sales AE, Wittmann DA. Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer. Implement Sci Commun 2021; 2:124. [PMID: 34711274 PMCID: PMC8555144 DOI: 10.1186/s43058-021-00224-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel's Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development. METHODS We used national cancer registry and administrative data from 2016 to 2017 to examine the variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high- and low-performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B model to generate a conceptual framework for addressing low-value ADT practices. RESULTS Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment, including barriers and facilitators to de-implementing low-value ADT. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe 2); willing, under some circumstances, to prescribe: and 3) prescribe as an acceptable treatment option. Provider capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social roles and influences regarding ADT practices, such as prior training. Provider motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence, and beliefs about the consequences of prescribing or not prescribing ADT. CONCLUSIONS Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer. TRIAL REGISTRATION ClinicalTrials.gov , NCT03579680.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Megan V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly Dossett
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Alan Paniagua-Cruz
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | | | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
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40
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Stensland KD, Kaffenberger SD, George AK, Morgan TM, Miller DC, Salami SS, Dunn RL, Palapattu GS, Montgomery JS, Hollenbeck BK, Skolarus TA. Prostate cancer clinical trial completion: The role of geography. Contemp Clin Trials 2021; 111:106600. [PMID: 34673273 DOI: 10.1016/j.cct.2021.106600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/23/2021] [Accepted: 10/14/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND/AIMS One in five cancer clinical trials fails with another third failing to meet enrollment goals. Prior efforts to improve enrollment focus on patient facing interventions, but geographic factors such as regional cancer incidence may doom trials before they even begin. For these reasons, we examined associations of regional prostate cancer incidence with trial termination, and identified scientifically-underserved areas where future trials might thrive. METHODS We merged US phase 2-3 prostate cancer clinical trial data from ClinicalTrials.gov with prostate cancer incidence data from statecancerprofiles.cancer.gov. We matched trial information from 293 closed and 560 active trials with incidence data for 2947 counties. Using multivariable logistic regression, we identified associations with trial termination. We identified 'scientifically-underserved' counties with the highest cancer incidence quintile (>61 annual cases) but lowest active trials quintile (0 or 1 trial). RESULTS Of 293 closed trials, one in three was terminated (n = 96, 32.8%). On multivariable analysis, only lower regional prostate cancer incidence was associated with higher likelihood of premature trial termination (OR 0.98, 95% CI [0.96-0.99] for every 100 cases, p = 0.03). We identified 188 counties with >61 annual prostate cancer cases but 0 or 1 active trials, indicating potential scientifically-underserved areas. CONCLUSIONS In this novel study, we found prostate cancer trials in areas with low prostate cancer incidence were more likely to fail. We also identified scientifically-underserved areas where trials might thrive. Our findings provide a more nuanced understanding of clinical trial feasibility and upstream opportunities for improvement.
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Affiliation(s)
- Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan, USA; Department of Urology, Division of Urologic Oncology, University of Michigan, USA
| | | | - Arvin K George
- Department of Urology, Division of Urologic Oncology, University of Michigan, USA; VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, USA
| | - Todd M Morgan
- Department of Urology, Division of Urologic Oncology, University of Michigan, USA
| | - David C Miller
- Department of Urology, Dow Division of Health Services Research, University of Michigan, USA; Department of Urology, Division of Urologic Oncology, University of Michigan, USA
| | - Simpa S Salami
- Department of Urology, Division of Urologic Oncology, University of Michigan, USA
| | - Rodney L Dunn
- Department of Urology, Dow Division of Health Services Research, University of Michigan, USA
| | - Ganesh S Palapattu
- Department of Urology, Division of Urologic Oncology, University of Michigan, USA
| | - Jeffrey S Montgomery
- Department of Urology, Division of Urologic Oncology, University of Michigan, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan, USA; Department of Urology, Division of Urologic Oncology, University of Michigan, USA
| | - Ted A Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan, USA; Department of Urology, Division of Urologic Oncology, University of Michigan, USA; VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, USA.
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Radhakrishnan A, Subramanian L, Rankin A, Skolarus TA, Wittmann D, Hawley ST, Fetters M. Optimizing active surveillance for low-risk prostate cancer: Characterizing provider and patient perspectives. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
250 Background: The number of men on active surveillance (AS) for low-risk prostate cancer is rapidly increasing. While AS requires routine clinical exams, labs, imaging, and prostate biopsies, many men do not receive all recommended components. Understanding the perspectives of key stakeholders regarding recommended surveillance is critical to ensuring the optimization of AS as a management strategy. Methods: We conducted in-depth, semi-structured, virtual interviews with a purposive sample of 15 men with low-risk prostate cancer who were on AS as their primary management strategy and their partners, and 15 urologists and 19 primary care providers (PCPs) with experience in AS management between June 2020 and March 2021. We used the Theoretical Domains Framework (TDF), an implementation science framework developed to understand determinants of behaviors and to inform the design of interventions, to guide our interview guide. Questions assessed knowledge, barriers and facilitators, and preferences for provider roles in AS management. Interviews were recorded, transcribed, and deductively coded into TDF domains and constructs. Three independent coders iteratively developed and used a shared coding framework. Participant recruitment continued until data saturation by group. Results: Our study included 15 men (on AS between 1-16 years), 5 partners, 15 urologists (3 female, 5 in private practice, 3 in academic medical centers), and 19 PCPs (9 female, 4 in community practices, 15 in academic medical centers). The TDF domain of “knowledge” and the construct, “barriers and facilitators” were most commonly reported as factors impacting receipt of recommended surveillance across all groups. While urologists were most knowledgeable about AS, PCPs noted limitations in understanding for whom AS is recommended, and what it entails. Patients who had made an effort to research or learn about AS found that this knowledge enabled them to be proactive about receiving all recommended components. Urologists and patients noted several common procedural barriers to receiving recommended surveillance, including pain with repeated biopsies, and becoming lost to follow-up. Patients and PCPs were uncertain about what tests were needed and when. Urologists were concerned about PCP knowledge while PCPs described insufficient communication from urologists as barriers to shared care. Procedural facilitators included electronic medical records (EMR) to remind providers and patients of frequency and timing of tests. Conclusions: Key opportunities for optimizing AS include improving patient and PCP knowledge about the components and delivery of AS, facilitating communication between providers, and leveraging EMR to ensure those on AS are followed. The development of an intervention that combines several of these components will be critical to ensuring men on AS receive the recommended surveillance.
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Affiliation(s)
| | | | | | | | - Daniela Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI
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Soerensen SJC, Thomas IC, Schmidt B, Daskivich TJ, Skolarus TA, Jackson C, Osborne TF, Chertow GM, Brooks JD, Rehkopf DH, Leppert JT. AUTHOR REPLY. Urology 2021; 155:76. [PMID: 34489006 DOI: 10.1016/j.urology.2021.05.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/09/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Simon John Christoph Soerensen
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - I-Chun Thomas
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Bogdana Schmidt
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | | | - Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI
| | - Christian Jackson
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Thomas F Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Glenn M Chertow
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - James D Brooks
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - David H Rehkopf
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - John T Leppert
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Urology, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Marchetti KA, Oerline M, Hollenbeck BK, Kaufman SR, Skolarus TA, Shahinian VB, Caram MEV, Modi PK. Urology Workforce Changes and Implications for Prostate Cancer Care Among Medicare Enrollees. Urology 2021; 155:77-82. [PMID: 33610652 PMCID: PMC8374001 DOI: 10.1016/j.urology.2020.12.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/28/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To characterize national trends in urologist workforce, practice organization, and management of incident prostate cancer. METHODS Using Medicare claims data from 2010 to 2016, we identified all urologists billing Medicare and the practice with which they were affiliated. We characterized groups as solo, small single specialty, large single specialty, multispecialty, specialist, or hospital-owned practices. Using a 20% sample of national Medicare claims, we identified all patients with incident prostate cancer and identified their primary treatment. RESULTS The number of urologists increased from 9,305 in 2010 to 9,570 in 2016 (P = .03), while the number of practices decreased from 3,588 to 2,861 (P < .001). The proportion of urologists in multispecialty groups increased from 17.1% in 2010 to 28.2% in 2016, while those within solo practices declined from 26.2% to only 15.8% over the same time period. A higher proportion of patients at hospital-owned practices were treated with observation (P < .001) and surgery (P < .001), while a higher proportion of patients at large single specialty practices were treated with radiation therapy (P < .001). CONCLUSION We characterized shifts in urologist membership from smaller, independent groups to larger, multispecialty or hospital-owned practices. This trend coincides with higher utilization of observation and surgical treatment for prostate cancer.
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Affiliation(s)
- Kathryn A Marchetti
- Division of Health Services Research, Department of Urology, University of Michigan.
| | - Mary Oerline
- Division of Health Services Research, Department of Urology, University of Michigan
| | - Brent K Hollenbeck
- Division of Health Services Research, Department of Urology, University of Michigan
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan
| | - Ted A Skolarus
- Division of Health Services Research, Department of Urology, University of Michigan; Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System
| | - Vahakn B Shahinian
- Division of Health Services Research, Department of Urology, University of Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Megan E V Caram
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Parth K Modi
- Division of Health Services Research, Department of Urology, University of Michigan
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Caram ME, Burns J, Kumbier K, Sparks JB, Tsao PA, Chapman CH, Bauman J, Hollenbeck BK, Shahinian VB, Skolarus TA. Factors influencing treatment of veterans with advanced prostate cancer. Cancer 2021; 127:2311-2318. [PMID: 33764537 PMCID: PMC8195818 DOI: 10.1002/cncr.33485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/01/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Treatments for metastatic castration-resistant prostate cancer (CRPC) differ in toxicity, administration, and evidence. In this study, clinical and nonclinical factors associated with the first-line treatment for CRPC in a national delivery system were evaluated. METHODS National electronic laboratory and clinical data from the Veterans Health Administration were used to identify patients with CRPC (ie, rising prostate-specific antigen [PSA] on androgen deprivation) who received abiraterone, enzalutamide, docetaxel, or ketoconazole from 2010 through 2017. It was determined whether clinical (eg, PSA) and nonclinical factors (eg, race, facility) were associated with the first-line treatment selection using multilevel, multinomial logistic regression. The average marginal effects (AMEs) were calculated of patient, disease, and facility characteristics on ketoconazole versus more appropriate CRPC therapy. RESULTS There were 4998 patients identified with CRPC who received first-line ketoconazole, docetaxel, abiraterone, or enzalutamide. After adjustment, increasing age was associated with receipt of abiraterone (adjusted odds ratio [aOR], 1.07; 95% credible interval [CrI], 1.06-1.09) or enzalutamide (aOR, 1.10; 95% CrI, 1.08-1.11) versus docetaxel. Greater preexisting comorbidity was associated with enzalutamide versus abiraterone (aOR, 1.53; 95% CrI, 1.23-1.91). Patients with higher PSA values at the start of treatment were more likely to receive docetaxel than oral agents and less likely to receive ketoconazole than other oral agents. African American men were more likely to receive ketoconazole than abiraterone, enzalutamide, or docetaxel (AME, 2.8%; 95% CI, 0.7%-4.9%). This effect was attenuated when adjusting for facility characteristics (AME, 1.9%; 95% CI, -0.4% to 4.1%). CONCLUSIONS Clinical factors had an expected effect on the first-line treatment selection. Race may be associated with the receipt of a guideline-discordant first-line treatment.
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Affiliation(s)
- Megan E.V. Caram
- Department of Internal Medicine, University of Michigan Medical School
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jennifer Burns
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Kyle Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jordan B. Sparks
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Phoebe A. Tsao
- Department of Internal Medicine, University of Michigan Medical School
| | - Christina H. Chapman
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Radiation Oncology, University of Michigan Medical School
| | - Jordan Bauman
- Department of Internal Medicine, University of Michigan Medical School
| | | | - Vahakn B. Shahinian
- Department of Internal Medicine, University of Michigan Medical School
- Department of Urology, University of Michigan Medical School
| | - Ted A. Skolarus
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Urology, University of Michigan Medical School
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Radhakrishnan A, Wallner LP, Skolarus TA, Shahinian VB, Abrahamse PH, Fetters MD, Hawley ST. Primary Care Physician Perspectives on Low Risk Prostate Cancer Management: Results of a National Survey. Urol Pract 2021; 8:515-522. [PMID: 35969833 PMCID: PMC9365261 DOI: 10.1097/upj.0000000000000231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/20/2021] [Indexed: 11/25/2022]
Abstract
Introduction Primary care providers can collaborate with urologists to ensure men with low risk prostate cancer on active surveillance receive followup testing and adhere to the management strategy, yet primary care provider attitudes about active surveillance and their roles remain unknown. Methods We surveyed 1,000 primary care providers (347/741 eligible primary care providers responded). We assessed primary care provider support for and beliefs about active surveillance, and attitudes about and preferences for their role in various aspects of low risk prostate cancer management. We then examined associations between 1) primary care provider support for and primary care provider beliefs about active surveillance; and 2) primary care provider attitudes and preferences for their role. Results Nearly 50% of primary care providers strongly supported active surveillance for all low risk men, and 81% strongly agreed that active surveillance allows men to avoid side effects, while 57% strongly agreed it caused worry. Primary care providers who strongly supported active surveillance were less likely to strongly agree that active surveillance contributes to worry (50.3% vs 63.7% respectively, p=0.01). Half of the primary care providers strongly agreed that primary care providers can provide cancer-related care (50.5%), and the majority preferred a shared care model to ordering prostate specific antigen tests (60.1%). Primary care providers who strongly agreed that primary care providers can provide cancer-related care were more likely to prefer a primary care provider-led (79.3% vs 20.7%) or shared care (53.9% vs 46.1%) model vs urologist-led for ordering prostate specific antigen tests (p <0.01). Conclusions While many primary care providers supported active surveillance for low risk prostate cancer, primary care providers still had concerns with it as the primary management strategy. Understanding primary care providers perspectives on low risk prostate cancer management can inform strategies to improve high quality active surveillance care.
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Affiliation(s)
| | - Lauren P. Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Ted A. Skolarus
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Vahakn B. Shahinian
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Department of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Paul H. Abrahamse
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Michael D. Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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46
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Stensland KD, Skolarus TA. EDITORIAL COMMENT. Urology 2021; 153:145-146. [PMID: 34311908 DOI: 10.1016/j.urology.2020.11.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Ted A Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI
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Soerensen SJC, Thomas IC, Schmidt B, Daskivich TJ, Skolarus TA, Jackson C, Osborne TF, Chertow GM, Brooks JD, Rehkopf DH, Leppert JT. Using an Automated Electronic Health Record Score To Estimate Life Expectancy In Men Diagnosed With Prostate Cancer In The Veterans Health Administration. Urology 2021; 155:70-76. [PMID: 34139251 DOI: 10.1016/j.urology.2021.05.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/11/2021] [Accepted: 05/09/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine if an automatically calculated electronic health record score can estimate intermediate-term life expectancy in men with prostate cancer to provide guideline concordant care. METHODS We identified all men (n = 36,591) diagnosed with prostate cancer in 2013-2015 in the VHA. Of the 36,591, 35,364 (96.6%) had an available Care Assessment Needs (CAN) score (range: 0-99) automatically calculated in the 30 days prior to the date of diagnosis. It was designed to estimate short-term risks of hospitalization and mortality. We fit unadjusted and multivariable Cox proportional hazards regression models to determine the association between the CAN score and overall survival among men with prostate cancer. We compared CAN score performance to two established comorbidity measures: The Charlson Comorbidity Index and Prostate Cancer Comorbidity Index (PCCI). RESULTS Among 35,364 men, the CAN score correlated with overall stage, with mean scores of 46.5 ( ± 22.4), 58.0 ( ± 24.4), and 68.1 ( ± 24.3) in localized, locally advanced, and metastatic disease, respectively. In both unadjusted and adjusted models for prostate cancer risk, the CAN score was independently associated with survival (HR = 1.23 95%CI 1.22-1.24 & adjusted HR = 1.17 95%CI 1.16-1.18 per 5-unit change, respectively). The CAN score (overall C-Index 0.74) yielded better discrimination (AUC = 0.76) than PCCI (AUC = 0.65) or Charlson Comorbidity Index (AUC = 0.66) for 5-year survival. CONCLUSION The CAN score is strongly associated with intermediate-term survival following a prostate cancer diagnosis. The CAN score is an example of how learning health care systems can implement multi-dimensional tools to provide fully automated life expectancy estimates to facilitate patient-centered cancer care.
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Affiliation(s)
- Simon John Christoph Soerensen
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - I-Chun Thomas
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Bogdana Schmidt
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | | | - Ted A Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Ann Arbor, MI
| | - Christian Jackson
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Thomas F Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Glenn M Chertow
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - James D Brooks
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - David H Rehkopf
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - John T Leppert
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA.
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Bauman J, Kumbier K, Burns JA, Sparks J, Tsao PA, Skolarus TA, Shahinian VB, Caram MV. Bone modifying agents in veterans with castration-resistant prostate cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.6582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6582 Background: Skeletal related events (SREs) are a known complication for the 80% of men with metastatic prostate cancer who have bone metastases. Previous studies have demonstrated that bone modifying agents (BMAs) such as zoledronic acid and denosumab reduce SREs in men with metastatic castration-resistant prostate cancer who have bone metastases and are now recommended by national guidelines. We sought to investigate factors associated with use of BMAs in Veterans with CRPC across the Veterans Health Administration (VA). Methods: Using the VA Corporate Data Warehouse, consisting of aggregated medical record data from 130 facilities, we used an algorithm previously published to identify men with a diagnosis of castration-resistant prostate cancer (CRPC) based on rising prostate specific antigen (PSA) levels while on androgen deprivation therapy and who received systemic treatment for CRPC with one of the commonly used therapies: abiraterone, enzalutamide, docetaxel, ketoconazole between 2010 and 2017. To account for clustering among facilities, we used a multilevel multivariable logistic regression to determine the association of patient and disease-specific variables on the odds of a patient receiving a BMA after they started treatment for CRPC. Results: Of 4,998 patients with CRPC in our cohort, 2223 (44%) received either zoledronic acid or denosumab at some point after they were initiated on treatment for CRPC. After adjusting for other variables and accounting for a facility, the odds of receiving a BMA decreased by 3% for every additional year of age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.96-0.98), and decreased significantly with increasing comorbid conditions (OR 0.94, 95% CI 0.72-0.98 for Charlson Comorbidity Index [CCI] of 1; OR 0.69, 95% CI 0.59-0.81 for CCI 2+). Patients who were Black had 25% lower odds of receiving a BMA than patients who were White (OR 0.75, 95% CI 0.65-0.87). PSA at time of CRPC treatment start had a small but not significant effect on receipt of a BMA (OR 1.04, 95% CI 1.00-1.08) for every unit increase of PSA on the log scale. PSA doubling time was not associated with receipt of a BMA. The presence of a diagnosis code for bone metastases was far lower than expected in this cohort of patients with CRPC (40.7%), and thus was not included in the model. We did not expect the presence of bone metastases to vary significantly among the other independent variables. Conclusions: Despite most patients with CRPC historically having bone metastases, less than half of patients with CRPC received a BMA. Patients who are older, had more comorbidities, or were Black were less likely to receive a BMA after starting treatment for CRPC. Understanding factors that lead to different patterns of treatment can guide initiatives toward more guideline-concordant care.
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Affiliation(s)
| | - Kyle Kumbier
- Ann Arbor Veterans Health Administration, Ann Arbor, MI
| | | | - Jordan Sparks
- Ann Arbor Veterans Health Administration, Ann Arbor, MI
| | - Phoebe A. Tsao
- Department of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | | | | | - Megan Veresh Caram
- Department of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
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Tsao PA, Burns JA, Entenman S, Kumbier K, Sparks J, Bohnert ASB, Skolarus TA, Caram MV. Mental health care utilization among veterans with castration-resistant prostate cancer receiving abiraterone or enzalutamide. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18680 Background: Abiraterone and enzalutamide are oral therapies widely used to treat men with castration-resistant prostate cancer (CRPC). Recent data have suggested potentially worsened quality of life and depression with use of enzalutamide compared to abiraterone. Because Veterans are at a higher risk for mental health conditions, we sought to compare mental health service utilization in Veterans with CRPC receiving enzalutamide to those receiving abiraterone. Methods: The Veterans Health Administration Corporate Data Warehouse was used to identify men with CRPC who received abiraterone or enzalutamide for ≥ 30 days as first-line treatment between 2010-2017. We compared the rate of mental health visits per 100 patient-months for men on abiraterone versus enzalutamide using an exact rate ratio test, assuming Poisson counts. Results: Among 2902 male Veterans, 68.6% (n=1992) received abiraterone and 31.4% (n=910) enzalutamide as first-line therapy. Men who received enzalutamide were older (76 vs 74, p<0.01) and had a higher comorbidity burden (Charlson Comorbidity Index [CCI] ≥ 2 in 28.7% vs 21.6%, p<0.01); no differences were noted in race or prevalence of preexisting documented mental health diagnoses. Median time on drug was 8 months for both medications. There was no difference in the rate of mental health visits per 100 patients-months on enzalutamide versus abiraterone (6.6 v. 6.7, p=0.66). However, within patient sub-groups, men who were age 75 or older, not married, or without notable comorbidities had lower rates of mental health visits with enzalutamide compared to abiraterone; whereas those who were younger than 75, married, had higher comorbidities, or a preexisting mental health diagnosis had higher rates of mental health visits with enzalutamide (Table). Conclusions: Among Veterans with CRPC who received a novel antiandrogen therapy first-line, there was no difference in engagement in mental health care between those who received abiraterone versus enzalutamide. Sub-group analysis revealed significant differences between patients on the two medications in demographic and diagnostic characteristics associated with number of visits, suggesting that vulnerability for mental health symptoms may vary by medication type. Further work in understanding the long-term impact of novel antiandrogens on mental health is needed.[Table: see text]
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Affiliation(s)
- Phoebe A. Tsao
- Department of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | | | | | - Kyle Kumbier
- Ann Arbor Veterans Health Administration, Ann Arbor, MI
| | - Jordan Sparks
- Ann Arbor Veterans Health Administration, Ann Arbor, MI
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Megan Veresh Caram
- Department of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
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50
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Lamb BW, Miah S, Skolarus TA, Stewart GD, Green JSA, Sevdalis N, Soukup T. Development and Validation of a Short Version of the Metric for the Observation of Decision-Making in Multidisciplinary Tumor Boards: MODe-Lite. Ann Surg Oncol 2021; 28:7577-7588. [PMID: 33974197 PMCID: PMC8519835 DOI: 10.1245/s10434-021-09989-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/02/2021] [Indexed: 01/08/2023]
Abstract
Background Evidence-based tools are necessary for scientifically improving the way MTBs work. Such tools are available but can be difficult to use. This study aimed to develop a robust observational assessment tool for use on cancer multidisciplinary tumor boards (MTBs) by health care professionals in everyday practice. Methods A retrospective cross-sectional observational study was conducted in the United Kingdom from September 2015 to July 2016. Three tumor boards from three teaching hospitals were recruited, with 44 members overall. Six weekly meetings involving 146 consecutive cases were video-recorded and scored using the validated MODe tool. Data were subjected to reliability and validity analysis in the current study to develop a shorter version of the MODe. Results Phase 1, a reduction of the original items in the MODe, was achieved through two focus group meetings with expert assessors based on previous research. The 12 original items were reduced to 6 domains, receiving full agreement by the assessors. In phase 2, the six domains were subjected to item reliability, convergent validation, and internal consistency testing against the MODe-Lite global score, the MODe global score, and the items of the MODe. Significant positive correlations were evident across all domains (p < 0.01), indicating good reliability and validity. In phase 3, feasibility and high inter-assessor reliability were achieved by two clinical assessors. Six domains measuring clinical input, holistic input, clinical collaboration, pathology, radiology, and management plan were integrated into MODe-Lite. Conclusions As an evidence-based tool for health care professionals in everyday practice, MODe-Lite gives cancer MTBs insight into the way they work and facilitates improvements in practice. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-09989-7.
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Affiliation(s)
- B W Lamb
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,School of Allied Health, Anglia Ruskin University, Cambridge, UK
| | - S Miah
- Department of Urology, Buckinghamshire Healthcare NHS Trust, Amersham, UK
| | - T A Skolarus
- VA Health Service Research and Development Center for Clinical Management Research, Ann Arbor, MI, USA.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - G D Stewart
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Surgery, University of Cambridge, Cambridge, UK
| | - J S A Green
- Whipps Cross University Hospital, Barts Health NHS Trust, London, UK.,Center for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - N Sevdalis
- Center for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - T Soukup
- Center for Implementation Science, Health Service and Population Research Department, King's College London, London, UK.
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