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2015 HSR&D/QUERI National Conference Abstract

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3160 — A Qualitative Study to Understand Inappropriate use of Imaging for Patients with Low Risk Prostate Cancer.

Makarov DV, VA NY Harbor Healthcare System; Sedlander E, New York University School of Medicine; Braithwaite S, New York University School of Medicine; Gold HT, New York University School of Medicine; Sherman SE, VA NY Harbor Healthcare System; Zeliadt SB, VA Puget Sound Health Care System; Shedlin M, New York University College of Nursing;

Objectives:
Prior research shows that Veteran Health Administration(VHA) hospitals inappropriately use imaging to stage patients with low risk prostate cancer, a practice that goes against national guidelines. Adherence to guidelines would reduce costs and improve quality of care. To better understand what drives inappropriate imaging, we wanted to understand both patient and physician attitudes and behaviors related to appropriate and inappropriate imaging.

Methods:
We invited veterans diagnosed with prostate cancer in the last six months from 2 large VHA hospitals as well as urologists from those hospitals to participate in individual semi-structured interviews. A total of 14 veterans completed in-person interviews and 14 urologists completed phone or in-person interviews. Questions for patients focused on decision making around imaging, feelings about radiation and knowledge about indications for imaging. Urologist interview questions focused on trust in guidelines, cost of care, fear of litigation, and reasons for going against suggested guidelines. Each interview was audio-recorded and transcribed. Transcripts were reviewed using a grounded theory approach and coded independently by two researchers. NVivo qualitative software was used for analysis.

Results:
No patients recalled any involvement in decision-making about imaging tests to stage their disease. When asked if patients wanted to be more involved, they said they were more concerned with treatment; no patients reported asking for an imaging test. All Urologists said they believe in clinical guidelines to improve quality of care and to control costs. However, many said they tend to image outside of guidelines due to fear of missed pathology, trust in their intuition over guidelines, and fear of litigation. Urologists discussed choosing to image rather than not as a "comfort" but also knowing and trusting the guidelines as "comfort," both in the context of legal protection.

Implications:
Although physicians say they trust imaging guidelines to encourage quality of care and to minimize cost, they often order imaging in excess of recommendations due to fear. This finding suggests a physician-targeted intervention to address their fear of missing potential metastatic disease is critical to reducing unnecessary care.

Impacts:
These results will inform a physician-focused intervention to encourage guideline-concordant imaging.