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Title: A multidisciplinary team oriented intervention to increase clinical practice guideline recommended care for patients with high-risk prostate cancer: a stepped wedge cluster randomised implementation trial
Authors: Brown B; Young J; Smith DP; Kneebone AB; Brooks AJ; Egger S; Xhilaga M; Dominello A; O’Connell DL; Haines M
Categories: Cancer Type - Prostate Cancer
Cancer Control, Survivorship, and Outcomes Research - Health Services, Economic and Health Policy Analyses
Year: 2018
Journal Title: Implementation Science
Volume: 13
Issue: 1
Page number start: 43
Abstract: Background: This study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations. Methods: Nine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals’ and study Sites’ practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists’ attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability. Results: Records for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the controlphase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%). Conclusions: The intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists’ attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect.
Division: Cancer Research Division
Funding Body: This research was funded under the National Health and Medical Research Council (NHMRC) of Australia partnership project scheme (ID: 1011474) with co-funding from the Prostate Cancer Foundation of Australia. DS was supported by an Australian National Health and Medical Research Council Training Fellowship (1016598).
DOI: 10.1186/s13012-018-0733-x
Appears in Collections:Research Articles

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