BACKGROUND/RATIONALE:
Almost half of Veterans with localized prostate cancer (the most common non-cutaneous malignancy among US men) undergo inappropriate, wasteful imaging. Before widespread PSA screening, most incident cases were advanced, requiring radiographic staging before treatment. In recent years, most new prostate cancer cases have been clinically localized; there is near unanimous agreement that routine radiographic staging is obsolete. While there have been efforts to curb this practice, imaging use to stage low-risk prostate cancer remains high. Results from the VA HSR&D CDA & CDP 11-257, upon which the current study builds, demonstrated that physicians, not patients, are the drivers of inappropriate imaging.

OBJECTIVE(S):
The objectives of this study are to: 1) determine whether the multi-modal, physician-focused Prostate Cancer Imaging Stewardship (PCIS) Intervention can improve facility-level guideline-concordant utilization of prostate cancer imaging; 2) use mixed methods to explore physician influence on guideline-concordant imaging; 3) determine the cost and cost impact of a physician-focused behavioral intervention to improve guideline-concordant prostate cancer imaging.

METHODS:
The PCIS Intervention is a novel combination of three evidence-based components targeting provider behavior change: Clinical Order Check, Academic Detailing, and Audit and Feedback. A Clinical Order Check will appear as an electronic reminder in computerized patient record system (CPRS) when a provider attempts to order imaging for a low-risk patient. Academic Detailing, or educational outreach, will occur at each institution quarterly throughout the intervention period to reinforce the project objectives and imaging guidelines. Audit and Feedback will be used to provide individual and facility-level feedback on prostate cancer imaging performance to participating providers quarterly throughout the intervention period. These data will be extracted from corporate data warehouse (CDW) and validated in VistA CAPRI (Compensation and Pension Record Interchange).

We will employ a stepped-wedge cluster-randomized design and implement the PCIS intervention across 10 VHA sites. In this design, the first time point will be a baseline measurement, where none of the study sites initiate the intervention. This is a single direction cross-over randomized trial where every site serves, at some point, as both control and an intervention site. This will allow for an accurate and fair reading of baseline imaging measures at each site. Quantitative data for this study will be extracted from VHA's CDW. VINCI, VHA's secure data environment will be used to identify prostate cancer patients in CDW as well as their imaging tests, demographic information, and clinical history. We will perform a cost analysis using the Health Economics Resource Center (HERC) Average Cost File. We will qualitatively explore providers' attitudes towards their respective institutions and the PCIS intervention through validated survey instruments and in-depth, semi-structured interviews.

FINDINGS/RESULTS:
Results are pending. We expect the PCIS intervention to decrease inappropriate prostate cancer imaging rates by a conservative estimate of 20% for low-risk patients and simultaneously increase appropriate prostate cancer imaging rates by a conservative estimate of 20% for high-risk patients. We expect the implementation of the PCIS intervention to result in a net savings for the health system, a figure to be calculated by a detailed cost analysis.

IMPACT:
This intervention is an opportunity to leverage VHA's state-of-the-art, integrated healthcare delivery system to implement a carefully designed, theory-based behavioral intervention to reduce harmful, inappropriate care, increase appropriate care to those who truly need it, and simultaneously save money for the healthcare system. Based on the results of the study, the PCIS Intervention toolkit will be available to be disseminated and implemented in other health settings to improve the quality of prostate cancer care for Veterans.

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External Links for this Project

NIH Reporter

Grant Number: I01HX002038-01A2
Link: https://reporter.nih.gov/project-details/9292723

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PUBLICATIONS:

Journal Articles

1. Ciprut SE, Kelly MD, Walter D, Hoffman R, Becker DJ, Loeb S, Sedlander E, Tenner CT, Sherman SE, Zeliadt SB, Makarov DV. A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study. Urology. 2020 Nov 1; 145:113-119. [view]
2. Leapman MS, Presley CJ, Zhu W, Soulos PR, Adelson KB, Miksad RA, Boffa DJ, Gross CP. Association of Programmed Cell Death Ligand 1 Expression Status With Receipt of Immune Checkpoint Inhibitors in Patients With Advanced Non-Small Cell Lung Cancer. JAMA Network Open. 2020 Jun 1; 3(6):e207205. [view]
3. Kirk PS, Borza T, Caram MEV, Shumway DA, Makarov DV, Burns JA, Shelton JB, Leppert JT, Chapman C, Chang M, Hollenbeck BK, Skolarus TA. Characterising potential bone scan overuse amongst men treated with radical prostatectomy. BJU international. 2019 Jul 1; 124(1):55-61. [view]
4. Grinberg AS, Sellinger JJ, Sprenkle PC, Bandin AJ, Nawaf CB, Syed JS, Leapman MS. Effect of Diaphragmatic Breathing on Procedural Anxiety During Transrectal Prostate Biopsy. Urology. 2020 Mar 1; 137:26-32. [view]
5. Salazar MC, Canavan ME, Walters SL, Herrin J, Schwartz JL, Leapman M, Boffa DJ. Evaluation of Cancer Care After Medicaid Expansion Under the Affordable Care Act. JAMA Network Open. 2020 Sep 1; 3(9):e2017544. [view]
6. Skokan AJ, Dobbs RW, Harris AM, Tessier CD, Sajadi KP, Talwar R, Berger I, Guzzo TJ, Ziemba JB. Implementing a patient safety culture survey to identify and target process improvements in academic ambulatory urology practices: a multi-institutional collaborative. The Canadian Journal of Urology. 2020 Feb 1; 27(1):10087-10092. [view]
7. Ghabili K, Park HS, Yu JB, Sprenkle PC, Kim SP, Nguyen KA, Ma X, Gross CP, Leapman MS. National trends in the management of patients with positive surgical margins at radical prostatectomy. World journal of urology. 2021 Apr 1; 39(4):1141-1151. [view]
8. Rajwa P, Hopen P, Mu L, Paradysz A, Wojnarowicz J, Gross CP, Leapman MS. Online Crowdfunding Response to Coronavirus Disease 2019. Journal of general internal medicine. 2020 Aug 1; 35(8):2482-2484. [view]
9. Ziemba JB, Tessier CD, Harris AM. Patient safety education and perceptions of safety culture in American and Canadian urological residency training programs. The Canadian Journal of Urology. 2020 Dec 1; 27(6):10431-10436. [view]
10. Makarov DV, Ciprut S, Kelly M, Walter D, Shedlin MG, Braithwaite RS, Tenner CT, Gold HT, Zeliadt S, Sherman SE. Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging. Trials. 2021 Oct 18; 22(1):711. [view]
11. Makarov DV, Holmes-Rovner M, Rovner DR, Averch T, Barry MJ, Chrouser K, Gee WF, Goodrich K, Haynes M, Krahn M, Saigal C, Sox HC, Stacey D, Tessier CD, Waterhouse RL, Fagerlin A. Quality Improvement Summit 2016: Shared Decision Making and Prostate Cancer Screening. Urology practice. 2018 Nov 1; 5(6):444-451. [view]
12. Miccio JA, Talcott WJ, Jairam V, Park HS, Yu JB, Leapman MS, Johnson SB, King MT, Nguyen PL, Kann BH. Quantifying treatment selection bias effect on survival in comparative effectiveness research: findings from low-risk prostate cancer patients. Prostate Cancer and Prostatic Diseases. 2021 Jun 1; 24(2):414-422. [view]
13. You H, Shang W, Min X, Weinreb J, Li Q, Leapman M, Wang L, Tian J. Sight and switch off: Nerve density visualization for interventions targeting nerves in prostate cancer. Science advances. 2020 Feb 1; 6(6):eaax6040. [view]
14. Hsiang W, Han X, Jemal A, Nguyen KA, Shuch B, Park H, Yu JB, Gross CP, Davidoff AJ, Leapman MS. The Association Between the Affordable Care Act and Insurance Status, Stage and Treatment in Patients with Testicular Cancer. Urology practice. 2020 Jul 1; 7(4):252-258. [view]
15. Becker DJ, Rude T, Walter D, Wang C, Loeb S, Li H, Ciprut S, Kelly M, Zeliadt SB, Fagerlin A, Lepor H, Sherman S, Ravenell JE, Makarov DV. The Association of Veterans' PSA Screening Rates With Changes in USPSTF Recommendations. Journal of the National Cancer Institute. 2021 May 4; 113(5):626-631. [view]

Journal Other

1. Abello A, Leapman M, Kenney PA. Chasing the Pack: Association between Urology Hospital Rankings and Surgical Outcome. [Editorial]. The Journal of urology. 2020 May 1; 203(5):890-891. [view]
2. Hsiang WR, Honig S, Leapman MS. Evaluation of Online Telehealth Platforms for Treatment of Erectile Dysfunction. [Editorial]. The Journal of urology. 2021 Feb 1; 205(2):330-332. [view]
3. Tessier CD. Patient Reported Shared Decision Making in Urology from the Surgical Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. [Editorial]. Urology practice. 2021 May 1; 8(3):https://doi.org/10.1097/UPJ.0000000000000216.01. [view]

DRA: Health Systems Science, Cancer
DRE: TRL - Applied/Translational, Treatment - Implementation
Keywords: Cancer, Clinical Diagnosis and Screening, Cost-Effectiveness, Implementation
MeSH Terms: none