White River Junction VA Medical Center, White River Junction, VT.
Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH.
JCO Oncol Pract. 2020 Aug;16(8):e668-e677. doi: 10.1200/JOP.19.00576. Epub 2020 Mar 2.
Many patients living with bladder cancer do not undergo surveillance that is aligned with their risk for recurrence or progression, which exposes them to unnecessary risk and burden of procedures. To implement risk-aligned surveillance as recommended by multiple guidelines, we need to understand patient-, provider-, and system-level factors contributing to the delivery of risk-aligned surveillance. In this study, we sought to systematically assess patient-level factors.
Guided by the Tailored Implementation for Chronic Diseases framework, we conducted semistructured interviews with 22 patients with bladder cancer undergoing surveillance cystoscopy procedures at three facilities within the Department of Veterans Affairs. Patients were sampled using quantitative data on bladder cancer risk category (low high) and on surveillance category (aligned not aligned with cancer risk). Interview transcripts were analyzed using a priori codes from the Tailored Implementation for Chronic Diseases framework. Quantitative and qualitative data were integrated by cross-tabulating determinants across risk and surveillance categories.
Participants included seven low-risk and 15 high-risk patients; 10 underwent risk-aligned surveillance and 12 did not. In mixed-methods analyses, perception of risk appropriately differed by risk but not by surveillance category. Participants understood the recommended surveillance schedule according to their risk category. Participants emphatically expressed that adhering to providers' recommendations is prudent; intentions to adhere did not vary across risk and surveillance categories.
Participants intended to adhere to providers' recommendations and strongly endorsed the importance of adherence. These findings suggest implementation strategies to improve risk-aligned surveillance may be most effective when targeting provider- and system-level factors rather than patient-level factors.
许多膀胱癌患者未接受与复发或进展风险相符的监测，这使他们面临不必要的风险和程序负担。为了实施多个指南推荐的风险相符监测，我们需要了解导致实施风险相符监测的患者、提供者和系统层面的因素。在这项研究中，我们旨在系统地评估患者层面的因素。
在慢性疾病定制实施框架的指导下，我们对在退伍军人事务部的三个设施接受膀胱镜检查监测程序的 22 名膀胱癌患者进行了半结构化访谈。根据膀胱癌风险类别（低 高）和监测类别（与癌症风险相符 不相符）的定量数据对患者进行抽样。使用慢性疾病定制实施框架的预先确定的代码对访谈记录进行分析。通过跨风险和监测类别交叉制表，整合了定量和定性数据。
参与者包括 7 名低危患者和 15 名高危患者；10 名患者接受了风险相符的监测，12 名患者没有。在混合方法分析中，对风险的感知适当地区别于风险，但不取决于监测类别。参与者根据自己的风险类别了解了推荐的监测计划。参与者强烈表示，遵守提供者的建议是谨慎的；遵守意愿在风险和监测类别之间没有差异。
参与者打算遵守提供者的建议，并强烈认可遵守的重要性。这些发现表明，改善风险相符监测的实施策略可能最有效地针对提供者和系统层面的因素，而不是患者层面的因素。
