Prostate Cancer Imaging Stewardship: a multimodal, physician-centered intervention for guideline-concordant imaging.

BACKGROUND: Inappropriate imaging to stage low-risk prostate cancer is considered low-value care. Determining the effectiveness of a theory-based intervention-Prostate Cancer Imaging Stewardship (PCIS)-to promote guideline-concordant imaging. METHODS: A stepped-wedge, cluster-randomized trial, PCIS, was conducted between March 2018 and March 2021 at 10 Veterans Health Administration medical centers (VAMCs) initially selected for prostate cancer volume, geographic diversity, and willingness to participate. Intervention initiations at sites were randomized in 3-month intervals. We enrolled 61 urology providers who treat prostate cancer at participating sites. Outcomes were assessed among 2302 patients with incident prostate cancer aged 18-85 years. PCIS combines 3 evidence-based provider-focused behavior change strategies: (1) Clinical Reminder Order Check triggered when a provider attempted to order imaging for a patient with prostate-specific antigen < 20 ng/mL, (2) VAMC-level academic detailing at initiation and every 3 months thereafter, and (3) Audit and Feedback for providers to improve their imaging performance. The main outcome was guideline-discordant nuclear medicine bone scan (NMBS) imaging for low-risk prostate cancer patients. RESULTS: NMBS imaging would be consistent with National Comprehensive Cancer Network guidelines in 878 patients (38%) and inconsistent in 1424 patients (62%). Among patients not requiring NMBS, 141/690 (20.4%) received guideline-discordant imaging (ie, NMBS ordered) during Control compared with 109/734 (14.9%) during Intervention (odds ratio [OR] = 0.54, P = .04). Among patients requiring a NMBS, 29 of 425 (6.8%) did not receive one (ie, guideline-discordant imaging) during Control compared with 25 of 453 (5.5%) during the Intervention (OR = 1.36, P = .36). CONCLUSION: PCIS significantly reduced low-value, guideline-discordant NMBS imaging among low-risk prostate cancer patients without negatively affecting necessary imaging for high-risk patients. CLINICAL TRIALS REGISTRATION: NCT03445559.