Randomized trials utilizing a single dose of intraoperative intravesical chemotherapy following transurethral bladder tumor resection have consistently demonstrated a reduction in bladder cancer recurrences. However, existing data suggests intraoperative intravesical chemotherapy is used infrequently, sometimes occurs in the wrong patients, and occurs only in a minority of cases. In this context, the candidate (Dr. Kelly Clinton Cary) seeks to determine the barriers to intraoperative intravesical chemotherapy and how to effectively develop and implement interventions to increase translation of this best available evidence into clinical practice. During the period of support, he will pursue additional didactic instruction in several disciplines, including graduate-level courses in qualitative research methods and implementation science, as well as conjoint analysis. He will also have ample opportunities for mentored, project-based learning, including the hands-on application of cognitive task analysis interview techniques, advanced statistical modeling with conjoint analysis, and implementation strategy design. The research plan has three specific aims:
Aim 1. To determine the barriers and facilitators to intraoperative intravesical chemotherapy utilization in non-muscle invasive bladder cancer. The candidate will conduct semi-structured interviews with key stakeholders directly or indirectly involved in the process of delivering intraoperative intravesical chemotherapy using the interview technique of cognitive task analysis. Key stakeholders will involve five distinct groups: 1) urologists, 2) patients, 3) pharmacists, 4) nurses, 5) administrative leaders. He hypothesizes it will be possible to identify several barriers and facilitators through the interview process.
Aim 2. To assess the relative importance of individual barriers and facilitators to intravesical chemotherapy utilization. The candidate will perform a conjoint analysis study using clinical vignettes to identify which barriers are most important in utilizing intravesical chemotherapy. This analysis will use a marketing research technique to determine which barriers and facilitators are most influential resulting in a rating of individual barriers. He hypothesizes that not all barriers and clinical factors are considered equally important or influential.
Aim 3. To develop intervention and implementation strategies to address the most important barriers to intravesical chemotherapy utilization. Using implementation science methods, intervention(s) and implementation strategies targeting the most important barriers and facilitators will be developed and iteratively improved using key stakeholders' input. He hypothesizes that well designed intervention and implementation strategies tailored to important barriers and facilitators with iterative input from key stakeholders can be developed to improve the delivery of evidence-based medicine. Completion of the proposed research will create a framework for answering the questions surrounding barriers in care and have an immediate impact for patients with bladder cancer in developing and implementing an intervention to reduce cancer recurrences.
The proposal will create a framework for identifying the barriers and facilitators to delivery of evidence-based medicine in bladder cancer care and their relative importance to one another while also informing the development and implementation of targeted interventions to facilitate the use of intraoperative intravesical chemotherapy to reduce cancer recurrences. More broadly, this model will be relevant to a wide range of medical conditions where there is insufficient translation of best available evidence into clinical practice.
