Determinants of Risk-aligned Bladder Cancer Surveillance - Mixed-Methods Evaluation using the Tailored Implementation for Chronic Diseases Framework
Florian R. Schroeck, MD, MS1, A. Aziz Ould Ismail, MD, MS2, Grace N. Perry, BA3, David Haggstrom, MD, MAS4, Steven L. Sanchez, BS4, DeRon Walker, MHA4, Jeanette Young, MA5, Susan Zickmund, PhD5, Lisa Zubkoff, PhD6.
1WRJ VAMC and Dartmouth College, Lebanon, NH, USA, 2WRJ VAMC, White River Junction, VT, USA, 3University of Utah, Salt Lake City, UT, USA, 4Roudeboush VA Medical Center, Indianapolis, IN, USA, 5Salt Lake City VA Medical Center, Salt Lake City, UT, USA, 6Birmingham/Atlanta VA GRECC, Birmingham, AL, USA.
BACKGROUND: Guidelines for surveillance of patients with non-muscle invasive bladder cancer recommend aligning surveillance frequency with underlying cancer risk. We previously found that risk-aligned surveillance is not commonly provided. Lack of risk-aligned surveillance means too many unnecessary surveillance cystoscopy procedures for low-risk patients and not enough surveillance for high-risk patients with associated delays in detection of cancer recurrence. This mixed-methods study sought to examine whether practice determinants differ between sites where risk-aligned surveillance was more common (“risk-aligned sites”) versus those where risk-aligned surveillance was less common (“need improvement sites”).
METHODS: We used our prior quantitative data to identify two “risk-aligned sites” and four “need improvement sites” within the Department of Veterans Affairs (VA). Across these sites, we sampled 40 VA staff members (18 bladder cancer providers, 5 nurses, 5 schedulers, and 12 leaders). We performed semi-structured interviews guided by the Tailored Implementation for Chronic Diseases framework that were deductively coded. We integrated quantitative data (“risk-aligned site” versus “need improvement site”) and qualitative data from the interviews by cross-tabulating salient determinants by site type (Table).
RESULTS: There were 14 participants from the two “risk-aligned sites” and 26 participants from the four “need improvement sites.” Irrespective of site type, we found a lack of knowledge on guideline recommendations. Additional salient determinants at “need improvement sites” were a lack of resources (“The next available without overbooking is probably seven to eight weeks out”) and an absence of standard routines to incorporate risk-aligned surveillance (“I have my own guidelines that I’ve been using for 35 years”).
CONCLUSIONS: Knowledge, resources, and lack of standard routines were salient barriers to risk-aligned bladder cancer surveillance. Implementation strategies addressing knowledge and resources can likely contribute to more risk-aligned surveillance. In addition, reminders for providers to incorporate risk into their surveillance plans may standardize their routines.
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