Multidisciplinary Treatment of Non-Spine Bone Metastases: Results of a Modified Delphi Consensus Process

Implementation Strategies to Promote Short-Course Radiation for Bone Metastases

“…Relevant constructs identified for this evidence-based practice included knowledge and/or beliefs, self-efficacy, and individual stage of change, further informing strategy selection targeting the individual physician level. The following 3 physician-level strategies were therefore selected from the Expert Recommendations for Implementing Change 27 and additional literature review, 18 , 19 , 20 with consideration for local context and preferences provided by site champions: (1) dissemination of professional educational materials (ie, electronic PDF of multidisciplinary consensus guidelines on the management of nonspine bone metastases) 24 ; (2) personalized audit-and-feedback reports, which described physician rates of short-course RT use during the baseline period, compared with peers at the same institution and institution-based aggregates from the other sites and MSK; and (3) an email-based consultation platform for community partners to request input from subspecialty experts for difficult cases called eConsults (see eAppendix 1 in Supplement 1 for additional information regarding each strategy).…”

“…The primary outcome was adherence to the consensus recommendation of short-course RT (ie, ≤5 fractions) for the treatment of nonspine bone metastases. 24 Patients with multiple lesions were counted by each separate course of treatment.…”

“…Third, physician identifiers were not included in surveys, which limits preimplementation and postimplementation paired testing and linking perceptual outcomes with practice outcomes. Fourth, possible explanations for observed practice improvement over time include (1) a potential Hawthorne effect, whereby physicians may have changed their practice because of their awareness of the study (which was grant funded and began with a consensus process involving the site champions, as described elsewhere) 24 rather than the study implementation strategies being tested, which is a challenge not uncommon in quality improvement given the desire to engage stakeholders (including site champions in the current study); (2) contamination between clinical sites, which was also possible in a sequential rollout design such as the stepped wedge (although no physicians changed to another institution during the study period, facilitating high adherence to study design); (3) an unrelated secular trend related to anticipation of a bundled payment model; and (4) an unrelated secular trend related to the emergence of randomized data supporting complex RT, although complex RT itself did not increase (data not shown). 11,46 JAMA Network Open | Oncology Nonetheless, our results emphasize the importance of formally evaluating quality improvement initiatives.…”

“…Therefore, there is a need to test implementation strategies that may help facilitate high-quality radiation care, particularly among the most vulnerable populations. 22,23 Building on consensus recommendations developed and published by our study team to help standardize treatment of patients with nonspine bone metastases (including preferred use of 5 fractions or fewer), 24 we designed a set of implementation strategies to align the clinical practice of radiation oncologists treating nonspine bone metastases across an existing academic-community partnership, known as the Memorial Sloan Kettering (MSK) Cancer Alliance. In the Alliance Group Initiative for Bone Metastases (ALIGNMENT) study, we assessed the feasibility, acceptability, and appropriateness of this set of implementation strategies, as well as the extent to which these strategies could improve uptake of evidence-based practice (ie, short-course RT) for nonspine bone metastases.…”