Determinants of Risk-Aligned Bladder Cancer Surveillance—Mixed-Methods Evaluation Using the Tailored Implementation for Chronic Diseases Framework

Abstract

PURPOSE: For many patients with cancer, the frequency of surveillance after primary treatment depends on the risk for cancer recurrence or progression. Lack of risk-aligned surveillance means too many unnecessary surveillance procedures for low-risk patients and not enough for high-risk patients. Using bladder cancer as an example, we examined whether practice determinants differ between Department of Veterans Affairs sites where risk-aligned surveillance was more (risk-aligned sites) or less common (need improvement sites). METHODS: We used our prior quantitative data to identify two risk-aligned sites and four need improvement sites. We performed semistructured interviews with 40 Veterans Affairs staff guided by the Tailored Implementation for Chronic Diseases framework that were deductively coded. We integrated quantitative data (risk-aligned site v need improvement site) and qualitative data from interviews, cross-tabulating salient determinants by site type. RESULTS: There were 14 participants from risk-aligned sites and 26 participants from 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 routines to incorporate risk-aligned surveillance (“I have my own guidelines that I've been using for 35 years”). CONCLUSION: Knowledge, resources, and lack of 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 improve their routines.

Data-driven approach to implementation mapping for the selection of implementation strategies: a case example for risk-aligned bladder cancer surveillance

“…It is important to acknowledge issues of equity and stakeholder preferences and values in the selection of implementation strategies. In our data-driven approach, equity and stakeholder preferences were included to the extent that they were represented in the prior mixed-methods assessments of staff needs [10]. However, diversity among stakeholders recruited for interviews and participation in advisory panels was somewhat limited with 8% African American and 2% Hispanic representation among interview participants [10] and no African American representation in our advisory panels.…”

“…The implementation mapping process was based on a needs assessment, for which we identified facilitators and barriers of risk-aligned bladder cancer surveillance. This was done via staff interviews across six Department of Veterans Affairs (VA) sites and has recently been published [10]. In this prior mixed-methods work, we used a quantitative approach to identify the six VA sites.…”

“…In this prior mixed-methods work, we used a quantitative approach to identify the six VA sites. Two sites commonly provided risk-aligned surveillance and four sites were deemed to have room for improvement, defined as sites which performed high intensity surveillance for low-risk and low intensity surveillance for high-risk early stage bladder cancer [10]. We purposively sampled 14 participants (6 providers, 2 nurses, 2 schedulers, 4 leaders) from risk-aligned sites and 26 participants (12 providers, 3 nurses, 3 schedulers, 8 leaders) from sites with room for improvement for semi-structured interviews.…”

“…The left column shows the specific Implementation Mapping tasks and the right column shows an example strategy that was selected and specified using Implementation Mapping future implementation strategies will need to address the lack of routines to incorporate risk-aligned surveillance into clinical workflow, potentially via reminders or templates. In addition, implementation strategies addressing knowledge and resources could likely contribute to more risk-aligned surveillance [10].…”

“…The performance objectives were organized by TICD framework domains and determinants and then by employee type (provider, nurse, scheduler, leader, patient). Performance objectives were formulated based on qualitative data from the prior staff interviews [10] and then reviewed and discussed in group sessions with the research team to assure they align with the qualitative data. These performance objectives were then discussed with one patient advisory group and one physician advisory group to solicit input.…”