Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Mar 12;13(1):43.
doi: 10.1186/s13012-018-0733-x.

A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial

Bernadette Brown  1   2 , Jane Young  3 , David P Smith  3   4   5 , Andrew B Kneebone  6   7 , Andrew J Brooks  8   9   10 , Sam Egger  4 , Miranda Xhilaga  11 , Amanda Dominello  12   3 , Dianne L O'Connell  3   4   13 , Mary Haines  12   3
Affiliations

A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial

Bernadette Brown et al. Implement Sci. .

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 control-phase 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.

Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910 ). Registered 6 December 2011.

PubMed Disclaimer

Conflict of interest statement

Ethics approval and consent to participate

Royal Prince Alfred Research Ethics Committee approved the CLICC implementation trial (ID: X12-0388 and HREC/12/RPAH/584). Site-specific approval (SSAs) was obtained from the research governance office at each of the nine Sites. Site-specific approval from Cancer Council NSW ethics committee was granted to cover data collection, storage and analysis at Cancer Council NSW. Participating clinicians provided informed written consent.

Consent for publication

Not applicable.

Competing interests

MX is employed by the Prostate Cancer Foundation of Australia (PCFA), and in October 2015, MH was appointed to the PCFA Research Advisory Committee, which has provided funds to support this research as part of the National Health and Medical Research Council (NHMRC) of Australia’s partnership project grant scheme (ID: 1011474). AB is the Co-Chair of the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network and MH is on the Research Sub-Committee of the Agency for Clinical Innovation Board. This Agency has provided in-kind funds as part of the National Health and Medical Research Council (NHMRC) of Australia’s partnership project grant scheme (ID: 1011474). AK is an investigator on the RAVES [Radiotherapy Adjuvant Vs Early Salvage] Trial (protocol number: TROG.08.03). The contents of this paper are solely the responsibility of the individual authors and do not reflect the views of the National Health and Medical Research Council of Australia, Prostate Cancer Foundation of Australia or NSW Agency for Clinical Innovation. JY was supported by a Cancer Institute NSW Academic Leader in Cancer Epidemiology award (08/EPC-1-01). DS was supported by an Australian National Health and Medical Research Council Training Fellowship (1016598). The other authors declare no support from any organisation for the submitted work, no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years and no other relationships or activities that could appear to have influenced the submitted work. The other authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
CLICC conceptual program logic framework
Fig. 2
Fig. 2
Timing of the intervention rollout in relation to date of prostatectomy 1Control-phase patients were those whose prostatectomy was performed between 1 January 2013 and 4 months before the CLICC intervention introductory session 2Transition-phase patients were those whose prostatectomy was performed between the date of the CLICC intervention introductory session and 4 months prior. This transition-phase was created because some transition patients could potentially benefit from the intervention while others could be referred or discussed before the intervention date and thus receive no such benefit 3Intervention-phase patients were those whose prostatectomy was performed after the CLICC intervention introductory session at the MDT to which the urologist belonged
Fig. 3
Fig. 3
CONSORT diagram
Fig. 4
Fig. 4
Patients’ referral pathways to radiation oncology or the RAVES trial. Percentages adjacent to connector lines represent the proportion of patients who continue from the previous category (box) into the next category. Percentages within categories (boxes) represent the proportion of all study patients, with the exception of “radiation < 6 months” where the denominator^ excludes those referred to RAVES. ^To account for RAVES referrals, the probability of radiation < 6 months is calculated as probability (consultation < 4 months) × probability(radiotherapy < 6 months|not RAVES referral) (= 27% × 63% = 17% for the control group; = 26% × 52% = 14% for the intervention group). months = months after prostatectomy
Fig. 5
Fig. 5
Association between changes in patient discussion at the MDT-level and changes in patient referral at the MDT-level during the intervention phase. Scatter points represent the MDT-specific RRs for referral (y-axis) and discussion (x-axis) within 4 months after prostatectomy as reported in Additional file 1: Tables S2 and S3. Numbers adjacent to the scatter points represent control:intervention percentages of patients discussed (left of scatter points) and referred (right of scatter points) within 4 months after prostatectomy. Scatter point sizes are proportional to numbers of patients. Solid line represents the predicted RRs for referral derived from regression model which effectively weights observations for Site sample size (patients); p = 0.001 for test of slope = 0
See this image and copyright information in PMC

References

    1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003;362(9391):1225–1230. doi: 10.1016/S0140-6736(03)14546-1. - DOI - PubMed
    1. Partin AW, Pound CR, Clemens JQ, Epstein JI, Walsh PC. Serum PSA after anatomic radical prostatectomy. The Johns Hopkins experience after 10 years. Urol Clin North Am. 1993;20(4):713–725. - PubMed
    1. Pound CR, Partin AW, Epstein JI, Walsh PC. Prostate-specific antigen after anatomic radical retropubic prostatectomy: patterns of recurrence and cancer control. Urol Clin N Am. 1997;24(2):395–406. doi: 10.1016/S0094-0143(05)70386-4. - DOI - PubMed
    1. Bolla M, van Poppel H, Tombal B, et al. Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911) Lancet. 2012;380(9858):2018–2027. doi: 10.1016/S0140-6736(12)61253-7. - DOI - PubMed
    1. Thompson I, Tangen C, Paradelo J, et al. Adjuvant radiotherapy for pathological T3N0M0 prostate cancer significantly reduces risk of metastases and improves survival: long-term followup of a randomized clinical trial. J Urol. 2009;181(3):956–962. doi: 10.1016/j.juro.2008.11.032. - DOI - PMC - PubMed

Publication types