The PCASP Implementation Science Project
Implementation science, a burgeoning field in public health research is the study of methods to promote the adoption and integration of evidence- based best practices, interventions, and policies into routine healthcare and public health settings to improve health in the population. It seeks to accelerate the uptake of best practices by ensuring that healthcare teams have the information and tools necessary to deliver the best care. With implementation science, researchers develop, test, and apply strategies that identify and overcome barriers that limit the provision of evidence-based care, such as the appropriate selection and use of high-quality active surveillance (AS) monitoring of patients with low-risk prostate cancer. The American Urological Association’s (AUA) national AQUA network provides a potential important implementation science tool for this purpose.
The PCASP research team has created an implementation science program to advance and sustain better outcomes for prostate cancer patients. Drs. Shellie Ellis, Michael Leapman, Stacy Loeb, Franklin Gaylis, Matthew Cooperberg, and Ronald Chen are developing a proposal to test implementation strategies to improve the selection and quality of active surveillance in the real-world setting. The strategies leveraged in this clinical trial will change provider and patient behavior to improve AS implementation to produce better outcomes for patients.
Currently, it is difficult for physicians to see how well their urology practice is performing. Electronic health records were designed largely to enhance coding and billing rather than as a vehicle to improve the quality of patient care. A systematic technology infrastructure for culling research and quality-of-care information is not currently in place. It takes time, money, and expertise to develop and execute this infrastructure, which is an important obstacle to the effective implementation and analysis of AS across practices, communities, states, and the nation. This lack of infrastructure also adversely impacts a physician’s ability to follow individual patients, which is critical for AS.
One strategy to increase the uptake and quality of AS, is called audit and feedback that provides a mechanism for the practice to observe the population of patients and see if patients are returning for follow-up visits when they should. Audit and feedback provide a metric that helps practitioners keep track of patients and bring them back for follow-up care. Dr. Gaylis at Unio Health Partners has been measuring the implementation of AS since 2011, when only 30% of eligible patients were adopting AS. After the Unio quality care team provided passive education to their physicians about AS, the percentage adopting AS increased to 38%. Unio’s quality improvement team then implemented an intervention- known as audited physician feedback, i.e., they showed the individual physicians their own performance compared to their partners’ performances anonymously. During the next three years, the appropriate adoption improved to 58%. Most recently, the practice added the intervention called transparency, i.e., the physicians saw their results compared to those of their identified partners. By 2022, the AS adoption rate increased to 83%, comparing favorably with national data, in which 40%-59% of low-risk patients adopt AS. Audit and feedback clearly improves the implementation and quality of AS, though by itself, it leaves room for improvement.
Another promising strategy involves realigning financial incentives to motivate the delivery of high-quality patient care. Historically, healthcare payment systems link reimbursement to active treatment services that disincentivizes observational strategies such as AS. Unlike active treatment with surgery, radiotherapy, or other interventional methods, AS is a management strategy that is implemented over time, based on the ongoing health of the patient, and the reimbursement to physicians occurs gradually over time. Evidence suggests that a restructuring compensation to include financial incentives for adopting AS in appropriate candidates might provide further motivation for physicians to adhere to clinical guideline recommendations. Such payments also provide support for physicians to reorganize their practices, set up protocols of care, and establish the necessary supporting infrastructure for high-quality AS. An accompanying PCASP proposal led by Dr. Ron Chen, an expert in cost-effectiveness research, will evaluate the various costs to the healthcare system of adopting high- quality AS for appropriate patient candidates.
Therefore, the PCASP initiative seeks to explore both audit and feedback and financial incentives as two potential implementation strategies that may be effective at overcoming barriers to AS monitoring. The PCASP team is planning to submit their proposal to the National Institutes of Health in 2024, with the over-arching goal of improving the quality and outcome of prostate cancer care, and doing it in a way that is sustainable and cost-effective. If successful, this project could have a substantial impact on the national management guidelines for patients with lower-risk (GG1 and favorable GG2) prostate cancer.