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cancer cases have been clinically localized; there is near unanimous agreement that routine radiographic staging is obsolete.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.
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.
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.
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.
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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- 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.
Health Systems, Cancer
Treatment - Implementation, TRL - Applied/Translational
Cancer, Clinical Diagnosis and Screening, Cost-Effectiveness, Implementation