Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer

• Published in: Implementation science communications Vol. 2; no. 1; pp. 124 - 16
• Main Authors: Skolarus, Ted A, Forman, Jane, Sparks, Jordan B, Metreger, Tabitha, Hawley, Sarah T, Caram, Megan V, Dossett, Lesly, Paniagua-Cruz, Alan, Makarov, Danil V, Leppert, John T, Shelton, Jeremy B, Stensland, Kristian D, Hollenbeck, Brent K, Shahinian, Vahakn, Sales, Anne E, Wittmann, Daniela A
• Format: Journal Article
• Language: English
• Published: England BioMed Central 28-10-2021; BMC
• Subjects: Behavior change; Behavioral theory; De-implementation; Implementation; Intervention; Low-value; Intervention; Complex health interventions; Low-value; Behavior change; Behavioral theory; De-implementation; Implementation
• ISSN: 2662-2211; 2662-2211
• DOI: 10.1186/s43058-021-00224-8

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.