(UroToday.com) The 2024 Bladder Cancer Advocacy Network (BCAN) Bladder Cancer Think Tank held in San Diego, CA between August 7th and 9th, 2024 was host to an implementation science session that addressed bridging evidence generation to practice in bladder cancer care.
One prime example of an implementation gap is the poor adoption of risk-adapted surveillance regimens for patients with non-muscle invasive bladder cancer (NMIBC). The current AUA guidelines recommend that for a low-risk patient whose first surveillance cystoscopy is negative for tumor, a clinician should perform a subsequent surveillance cystoscopy six to nine months later, and then annually thereafter. Conversely, for a high-risk patient whose first surveillance cystoscopy is negative for tumor, a clinician should perform subsequent cystoscopy with cytology every three to four months for two years.1 However, a significant proportion of low-risk patients undergo non-risk adapted surveillance strategies, with cystoscopy performed routinely every three months. This adversely impacts resource utilization, creates patient anxiety, and may cause unnecessary complications such as bleeding and infections. As such, there is a clear need for strategies to ‘bridge’ this implementation gap.
To assess whether risk-aligned surveillance is practiced within the US Department of Veterans Affairs facilities, Dr. Schroeck and colleagues conducted a national retrospective cohort study of patients diagnosed with low-risk or high-risk early-stage bladder between 2005 and 2014. In 70 of 85 facilities, surveillance was performed at a comparable frequency for low- and high-risk patients, differing by less than one cystoscopy over two years. Surveillance frequency among high-risk patients significantly exceeded surveillance among low-risk patients at only four facilities (circled in green in the image below).2
How do we evaluate the problem? One option is the use of the Tailored Implementation in Chronic Disease (TICD) project, which does not only apply to addressing chronic diseases. This framework includes domains related to:
- Incentives and resources
- Professional interactions
- Capacity for organizational change
- Guideline
- Individual health care provider
- Patient
- Social, political, and legal factors
To address the risk-adapted surveillance implementation gap, Dr. Schroeck and colleagues performed a qualitative analysis framework to identify the salient determinants – those that were mentioned most frequently or were conceptually important. They identified two ‘risk-aligned sites’ and four ‘need improvement’ sites. They performed semi-structured interviews with 40 Veterans Affairs staff guided by the TICD framework that were deductively coded.
Irrespective of site type, they 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").3
After identifying the salient determinants, how do can we select implementation strategies? In a follow-up study, Dr. Schroeck and colleagues evaluated all 73 Expert Recommendations for Implementing Change (ERIC) strategies, excluding those that were not applicable to their clinical setting. The remaining strategies were mapped to the objectives using data visualization techniques to make sense of the large matrices. They selected strategies with high impact, based on (1) broad scope, defined as a strategy addressing more than the median number of objectives, (2) requiring low or moderate time commitment from clinical teams, and (3) evidence of effectiveness from the literature.
After identifying and selecting the implementation strategies, Dr. Schroeck and colleagues proceeded to the ‘integration process’. This was a challenging aspect, as detailed in the slide below. The dark green boxes refer to strategies that were integrated across all sites with minimal timeline variation, the lighter green boxes to strategies that were integrated across all sites but with substantial timeline variation, and the yellow boxes to strategies that were not integrated across all sites. The ‘challenging’ strategies were to identify and prepare champions, audit and provide feedback, and remind clinicians.
An example of an implementation strategy employed was the creation and dissemination of risk-adapted surveillance grids that aim to overcome the knowledge gap that was evident from the prior studies.
What were the quantitative implementation outcomes? Those with high fidelity and sustainability were the tailoring and template strategies, whereas the designation of a site champion demonstrated low fidelity, and educational meetings demonstrated low sustainability (i.e., no attendance at the serial meetings). From a qualitative standpoint, the template and surveillance grids demonstrated excellent fidelity and sustainability for the following reasons:
How did these reflect quantitatively in clinical process outcomes? As demonstrated in the table below, following implementation of these strategies, the accuracy of documentation improved from 58% to 74%. The appropriateness of surveillance recommendations remained relatively stable at 85–87%; however, Dr. Schroeck that this was already good at baseline and thus hard to improve upon.
Specifically among the low-risk patients, the appropriateness of surveillance recommendations improved from 65% to 70% post-strategies implementation, and the accuracy of documentation improved from 32% to 83%.
Dr. Schroeck concluded that this represents an applied example of the use of frameworks to evaluate barriers and select, then test, implementation strategies. Strategies were well received overall. These efforts led to a 5% improvement in risk-aligned surveillance recommendations for low-risk patients.
Presented by: Florian R. Schroeck, MD, MS, Section Chief of Urology, White River Junction Veterans Affairs (VA) Medical Center, Associate Professor of Surgery, The Dartmouth Institute, Lebanon, NH
Written by: Rashid Sayyid, MD, MSc – Robotic Urologic Oncology Fellow at The University of Southern California, @rksayyid on Twitter during the 2024 BCAN Bladder Cancer Think Tank held in San Diego, CA between August 7th and 9th, 2024
References:- Holzbeierlein J, Bixler BR, Buckley DI, et al. Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline: 2024 amendment. J Urol. 2024;10.1097/JU.0000000000003846.
- Schroeck FR, Lynch KE, Chang JW, et al. Extent of Risk-Aligned Surveillance for Cancer Recurrence Among Patients With Early-Stage Bladder Cancer. JAMA Netw Open. 2018;1(5):e183442.
- Schroeck FR, Ismail AAO, Perry GN, et al. Determinants of Risk-Aligned Bladder Cancer Surveillance-Mixed-Methods Evaluation Using the Tailored Implementation for Chronic Diseases Framework. JCO Oncol Pract. 2022;18(1):e152-62.
- Schroeck FR, Ismail AAO, Haggstrom DA, et al. Data-driven approach to implementation mapping for the selection of implementation strategies: a case example for risk-aligned bladder cancer surveillance. Implement Sci. 2022;17(1):58.