Integration and Evaluation of Implementation Strategies to Improve Guideline-Concordant Bladder Cancer Surveillance

crossref(2024)

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Abstract Background Despite guideline recommendations, our prior work revealed that more than half of low-risk bladder cancer patients within the Department of Veterans Affairs (VA) undergo too many surveillance procedures and about a third of high-risk patients do not undergo enough procedures. Thus, we developed and integrated implementation strategies to improve risk-aligned bladder cancer surveillance for the VA system.Methods In prior work we conducted an Implementation Mapping process to develop nine implementation strategies: change record systems, educational meetings, champions, tailoring, preparing patients to be active participants, external facilitation, remind clinicians, audit & feedback, and a blueprint. In this work, we integrated these strategies as improvement approaches across four VA sites. The primary outcomes were qualitatively measured implementation outcomes, including appropriateness, acceptability, feasibility, and sustainability. Exploratory outcomes were quantitatively measured and included clinicians’ recommendations for guideline-concordant bladder cancer surveillance intervals.Results Changing record systems via a template in the electronic health record (EHR) was most impactful. Educational meetings and champions were critical for the integration of the strategies. The ability to tailor strategies contributed to clinician buy-in. Preparing patients to be active participants was helpful for clinicians and patients but time-consuming. Facilitation was key to launching the strategies. Some sites used and valued clinician reminders in the form of cheat sheets and posters, but this varied across sites. For low-risk patients, clinicians recommended guideline-concordant surveillance about 65% of the time at baseline, and this improved to 70% during evaluation. Across all risk groups, recommendations for guideline-concordant surveillance intervals were already present in more than 85% of baseline encounters and did not change. All sites sustained use of the changed EHR system, while sustainability of the other strategies was variable.Conclusions In general, strategies were successfully integrated and found to be appropriate, acceptable, and feasible. Future work should assess the impact of the improvement approaches on clinical care processes, particularly on reducing overuse of surveillance procedures among low-risk patients, as our study was not designed or powered to formally assess this outcome.Trial Registration The implementation strategies were not considered a healthcare intervention on human participants by the governing funding agency and IRB. Rather, they were seen as quality improvement interventions. Thus, this study did not meet criteria for a clinical trial and was not registered as such.
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