Candidate: Dr. Danil Makarov is a urologist and a fellowship-trained health services researcher. He plans, through this career development award, to gain additional expertise in health services research methodology and behavioral intervention. The candidate will collaborate with his primary mentor, an expert in physician behavioral intervention, as well as others expert in decision science, analysis of large datasets and qualitative methods. Mastery of these methodologies will allow the candidate to become an independent VA investigator, able to identify inefficiencies in medical practice and delivery as well as to design and implement strategies optimizing the delivery of medical care. Background: In the initial evaluation of prostate cancer (the most-commonly diagnosed non-cutaneous malignancy among US men), a patient's chances of receiving guideline-concordant imaging may be more dependent on the region in which he lives than on his disease characteristics. The propensity for clinicians to use imaging may vary across regions like settings on a thermostat, dialed up high in some areas where most patients receive scans and dialed down low in other areas where few are scanned. This suggests that policies focusing solely on reducing inappropriate imaging might simply act by dialing the thermostat down, potentially risking a reduction in appropriate imaging. In order to design and implement policies to optimize prostate cancer imaging, it is important to understand regional variation in prostate cancer imaging and the extent to which the thermostat model contributes to it. Project: The goals of the proposed research project are to understand the scope, the causes and the effects of regional variation in prostate cancer imaging.
In Specific Aim #1, the candidate will test the thermostat model in two new datasets comprising patients from the VA Central Cancer Registry and SEER- Medicare, representing systems with different payment models, system structures, and eligibility criteria. To understand further the potential causes of imaging variation the project will explore regional prostate cancer imaging rates across delivery systems (Specific Aim #2) and will contribute further depth and detail to these data using semi-structured interviews (Specific Aim #3) to determine physicians' and patients' attitudes regarding imaging. To determine the effects of regional imaging variation, the candidate will construct a decision analytic model (Specific Aim #4) assessing the tradeoffs in cost and disease detection of various imaging strategies. These model-based strategies will be compared to current care in order to determine the magnitude of possible benefit which a new strategy might deliver. The candidate will learn and utilize both qualitative and quantitative (mixed-methods) methodologies to address this question, as neither method could adequately do so in isolation. He will also learn decision analytic modeling and behavioral intervention, skils essential for the translation of effective practices into large healthcare systems. The candidate plans to use the acquired data and research experience as a foundation for an IIR application to develop and pilot a decision aid and behavioral intervention to optimize imaging use among veterans with incident prostate cancer.

Public Health Relevance

The goals of the proposed research project are to understand the scope, the causes and the effects of regional variation in prostate cancer imaging amongveterans. The candidate will learn and utilize both qualitative and quantitative (mixed-methods) methodologies as well as decision analysis to address this problem. The proposal will serve to improve the quality of healthcare delivered to veterans with prostate cancer and allow the candidate to develop into an independent investigator in the VA focused on cancer-related health services research.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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HSR&D Career Development Award (CDA0)
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VA Medical Center
New York
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Becker, Daniel J; Levy, Benjamin P; Gold, Heather T et al. (2018) Influence of Extent of Lymph Node Evaluation on Survival for Pathologically Lymph Node Negative Non-Small Cell Lung Cancer. Am J Clin Oncol 41:820-825
Makarov, Danil V; Li, Huilin; Lepor, Herbert et al. (2017) Teaching Hospitals and the Disconnect Between Technology Adoption and Comparative Effectiveness Research: The Case of the Surgical Robot. Med Care Res Rev 74:369-376
Becker, Daniel J; Lin, Daniel; Lee, Steve et al. (2017) Exploration of the ASCO and ESMO Value Frameworks for Antineoplastic Drugs. J Oncol Pract 13:e653-e665
Loeb, Stacy; Stork, Brian; Gold, Heather T et al. (2017) Tweet this: how advocacy for breast and prostate cancers stacks up on social media. BJU Int 120:461-463
Makarov, Danil V; Hu, Elaine Y C; Walter, Dawn et al. (2016) Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization. Health Serv Res 51:1021-51
Loeb, Stacy; Walter, Dawn; Curnyn, Caitlin et al. (2016) How Active is Active Surveillance? Intensity of Followup during Active Surveillance for Prostate Cancer in the United States. J Urol 196:721-6
Makarov, Danil V; Sedlander, Erica; Braithwaite, R Scott et al. (2016) A qualitative study to understand guideline-discordant use of imaging to stage incident prostate cancer. Implement Sci 11:118
Makarov, Danil V; Soulos, Pamela R; Gold, Heather T et al. (2015) Regional-Level Correlations in Inappropriate Imaging Rates for Prostate and Breast Cancers: Potential Implications for the Choosing Wisely Campaign. JAMA Oncol 1:185-94
Loeb, Stacy; Folkvaljon, Yasin; Makarov, Danil V et al. (2015) Five-year nationwide follow-up study of active surveillance for prostate cancer. Eur Urol 67:233-8
Wollin, Daniel A; Makarov, Danil V (2015) Guideline of Guidelines: Imaging of Localized Prostate Cancer. BJU Int 116:526-30

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