TPS270 Background: ~15,000 men with metastatic prostate cancer (MPCa) receiving care in the Veterans Administration (VA) could benefit from germline testing to inform treatment options. However, there are insufficient genetics providers to arrange for germline testing. In 2021, the VA implemented multiple strategies to shift the task of germline testing to oncologists (i.e., mainstreaming) to increase guideline-concordant germline testing. These efforts led to improved adoption of germline testing by oncologists, and mainstreaming was more efficient and timely than genetics referral. However, germline testing remains low for many oncologists due to numerous barriers, e.g., lack of preparedness and confidence in germline testing, from identifying eligible patients to results-informed management. Methods: We will conduct a cluster-randomized trial comparing the effectiveness of implementation strategies to increase mainstreaming through randomization of oncologists not meeting a pre-specified test-order benchmark of 25%. Eligible participants include VA oncologists who: 1) have authored progress notes in oncology clinics for ≥10 patients with MPCa in the past two years, 2) are practicing at VA facilities with germline test orders in the electronic health record (EHR), and 3) <25% of their MPCa patients have had mainstream germline test orders. In the first 6 months, we will disseminate a germline testing handbook with provider education materials, information resources and EHR tools. At month 7, for oncologists who do not exceed the 25% benchmark, we will administer audit-feedback reports describing their germline testing rates compared to peers and the 25% benchmark. At month 12, oncologists whose order rates are <25% will be randomized to either continue audit-feedback or receive facilitation (interactive problem-solving and support) and audit-feedback. At month 24, we will stop the audit-feedback and facilitation strategies. Throughout the project, we will conduct semi-structured interviews to understand local germline testing workflows, challenges and enabling factors. We will assess fidelity to the implementation strategies and any adaptations made using the Longitudinal Implementation Strategy Tracking System. To evaluate the effectiveness of the implementation strategies on germline testing, we will use a mixed-effects model to account for the clustered nature of the data and the effect sizes of the implementation strategies. The project is informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The study has not yet enrolled participants. There is no clinical trial registry number for this quality improvement project. This Department of Defense-funded project is a part of a greater quality improvement effort to increase guideline-concordant germline testing in the VA.
Kwon et al. (Sun,) studied this question.