Identifying, Understanding, and Overcoming Barriers to the Use of Clinical Practice Guidelines in Pediatric Oncology

Study Overview
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Brief Summary
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This research trial studies the use of clinical practice guidelines by pediatric oncology healthcare providers in order to identify, understand, and overcome barriers to them. The treatments for childhood cancers are intense and result in a high rate of symptoms which require support by healthcare providers. By reviewing patients' medical chart records, meeting in focus groups and in one-on-one interviews, healthcare providers may improve how clinical practice guidelines are used to support children undergoing cancer treatment.

Detailed Description
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PRIMARY OBJECTIVES: I. To measure the rate of adherence to selected Children's Oncology Group (COG)-endorsed supportive care clinical practice guidelines (CPG) recommendations at National Cancer Institute (NCI) Community Oncology Research Program (NCORP) sites. (Aim 1) II. To describe the possible influence of NCORP site size and the number of patients enrolled in COG studies per site on the delivery of CPG-consistent care. (Aim 1a) III. To describe the clinical outcome of episodes during which patients receive CPG-consistent or CPG-inconsistent care. (Aim 1b) IV. To describe facilitators of and barriers to the use of CPGs elicited via focus group interviews with a diverse set of potential users (physician, nurse, nurse practitioner and pharmacists) who provide pediatric cancer care at NCORP sites. (Aim 2) V. To improve how well CPG recommendations are understood by health care providers by refining the CPG recommendation format based on an iterative process of cognitive interviewing and formatting revisions. (Aim 3) OUTLINE: AIM 1 (CHART REVIEW): Patients are separated for each CPG evaluated (fever and neutropenia [FN], chemotherapy induced nausea and vomiting [CINV], fertility preservation [FP]) and are randomly selected for medical chart review. Patients with eligible episodes of FN, CINV or FP within the health records are selected and have the data from their records abstracted and reviewed by COG for adherence to COG endorsed CPGs. AIM 2 (FOCUS GROUPS): Health care providers who provide direct care to pediatric oncology patients are identified and separated to participate in three types of focus groups: physician-only, non-physician, and mixed. AIM 3 (INTERVIEWS): Health care providers undergo one-on-one interviews consisting of think aloud technique (TAL) of cognitive interviewing.

Official Title
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Use of Evidence-Based Supportive Care Clinical Practice Guidelines in Pediatric Oncology

Conditions
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Acute Lymphoblastic Leukemia, B-Cell Non-Hodgkin Lymphoma, Childhood Acute Myeloid Leukemia, Childhood Burkitt Lymphoma, Childhood Neoplasm, Hematopoietic and Lymphoid Cell Neoplasm, Malignant Solid Neoplasm, Recurrent Childhood Acute Lymphoblastic Leukemia

Intervention / Treatment
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* Other: Informational Intervention
* Other: Interview
* Other: Medical Chart Review
* Other: Questionnaire Administration


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Site willingness to participate in all 3 aims AIM 1 - ELIGIBILITY CRITERIA FOR INCLUSION IN RETROSPECTIVE CENTRALIZED CHART REVIEW Received care as an inpatient or outpatient at a participating COG NCORP site during the time period between January 1, 2014 and December 31, 2015 Ever enrolled on any COG trial (episode does not have to occur while on trial and the COG trial may be therapeutic or non-therapeutic) Has at least one episode eligible for FN, CINV or FP review CPG-Specific Eligibility FN Has any of the following diagnoses: Newly diagnosed acute lymphoblastic leukemia Relapsed acute lymphoblastic leukemia Any acute myeloid leukemia Burkitt's or mature B cell non-Hodgkin's lymphoma Any myeloablative autologous or allogeneic hematopoietic stem cell transplantation Developed FN at least once CINV Diagnosis of cancer Received moderately emetogenic chemotherapy as an inpatient < 12 years of age at the start of a CINV episode and received highly emetogenic chemotherapy as an in-patient FP Newly diagnosed cancer >= 15 years of age at cancer diagnosis Note: a single patient may contribute data for multiple episodes AIM 2 AND AIM 3 INCLUSION CRITERIA Healthcare professional currently employed at a participating COG NCORP institution Eligible healthcare providers include but are not limited to: physicians, nurses, nurse practitioners, pharmacists, social workers, dieticians, psychologists, and physical therapists/physiotherapists Provides direct care for children with cancer as part of current position at NCORP site Exclusion Criteria: AIM 2 AND AIM 3 EXCLUSION CRITERIA Trainees are excluded Previous participation in this study either for Aim 2 or Aim 3 Each health care provider can only be involved in one event (focus group or interview)

Ages Eligible for Study
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Maximum Age: 20 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Observational (chart review, focus group, interviews)<br>AIM 1 (CHART REVIEW): Patients are separated for each CPG evaluated (fever and neutropenia [FN], chemotherapy induced nausea and vomiting [CINV], fertility preservation [FP]) and are randomly selected for medical chart review. Patients with eligible episodes of FN, CINV or FP within the health records are selected and have the data from their records abstracted and reviewed by COG for adherence to COG endorsed CPGs. AIM 2 (FOCUS GROUPS): Health care providers who provide direct care to pediatric oncology patients are identified and separated to participate in three types of focus groups: physician-only, non-physician, and mixed. AIM 3 (INTERVIEWS): Health care providers undergo one-on-one interviews consisting of think aloud technique (TAL) of cognitive interviewing. | Other: Informational Intervention<br>* Participate in focus group<br>Other: Interview<br>* Undergo one-on-one interviews<br>Other: Medical Chart Review<br>* Review of medical chart<br>* Other names: Chart Review;Other: Questionnaire Administration<br>* Ancillary studies<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The proportion of clinical practice guidelines (CPG)-consistent care of fever and neutropenia (FN) episodes | FN will be identified by chart review. Outcome variable will be the binary endpoint of CPG-consistent versus (vs.) CPG inconsistent care for each FN episode. | Care delivered from January 1, 2014 through December 31, 2015 will be evaluated | 
| The proportion of CPG-consistent care of chemotherapy induced nausea and vomiting (CINV) episodes | CINV will be identified by chart review. Outcome variable will be the binary endpoint of CPG-consistent vs. CPG inconsistent care for each CINV episode (separately for high and moderate emetogenicity risk chemotherapy). | Care delivered from January 1, 2014 through December 31, 2015 will be evaluated | 
| The proportion of CPG-consistent care of fertility preservation (FP) episodes | FP will be identified by chart review. Outcome variable will be the binary endpoint of CPG-consistent vs. CPG inconsistent care for each FP episode. | Care delivered from January 1, 2014 through December 31, 2015 will be evaluated | 
| Possible influence of National Cancer Institute Community Oncology Research Program site size (Aim 1a) | Will be estimated and examined as fixed effect covariates in these generalized linear mixed effect models described above. | Care delivered from January 1, 2014 through December 31, 2015 will be evaluated | 
| Key coding categories (Aim 2) | Will be identified by the Framework for Clinical Practice Guideline Implementability. Operational definitions of each category will be determined. The implementation barriers and facilitators identified by focus group members will be coded using these categories independently by two investigators. New categories and sub-categories will be used to code concepts that do not fall within the pre-determined categories. Themes of commonality will be sought especially within the newly developed categories that fall outside the framework adapted from Gagliardi et al. Facilitators of and barriers to CPG implementation will be described. | Data collected from March 28, 2017 through October 15, 2018 will be evaluated | 
| CPG format which is well understood by pediatric oncology healthcare providers (Aim 3) | The issues identified via the interviews, changes made to the formatting, and rationale for the changes will be documented between each round in a tracking matrix. The proportion of interviewees who select the correct course of action when presented with four possible courses of action will be described for each iteration of the CPG format including the final version. Understanding is defined as the correct interpretation of the course of action recommended or suggested by a CPG. | Data collected from a minimum of 25 interviews starting from February 1, 2019 to the timepoint where a format that is well understood by participants is developed will be evaluated | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Clinical practice guidelines, supportive care, pediatrics