Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel's Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development.
We used national cancer registry and administrative data from 2016 to 2017 to examine the variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high- and low-performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B model to generate a conceptual framework for addressing low-value ADT practices.
Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment, including barriers and facilitators to de-implementing low-value ADT. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe 2); willing, under some circumstances, to prescribe: and 3) prescribe as an acceptable treatment option. Provider capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social roles and influences regarding ADT practices, such as prior training. Provider motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence, and beliefs about the consequences of prescribing or not prescribing ADT.
Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer.
ClinicalTrials.gov , NCT03579680.
Implementation science communications. 2021 Oct 28*** epublish ***
Ted A Skolarus, Jane Forman, Jordan B Sparks, Tabitha Metreger, Sarah T Hawley, Megan V Caram, Lesly Dossett, Alan Paniagua-Cruz, Danil V Makarov, John T Leppert, Jeremy B Shelton, Kristian D Stensland, Brent K Hollenbeck, Vahakn Shahinian, Anne E Sales, Daniela A Wittmann
VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. ., VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA., Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA., Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA., VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA., Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA., VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA., Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA., Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA.