Browsing by Author "Ould Ismail, A. Aziz"

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    Accurate Documentation Contributes to Guideline-concordant Surveillance of Non-Muscle Invasive Bladder Cancer: a Multi-site VA Study
    (Elsevier, 2023) Lyall, Vikram; Ould Ismail, A. Aziz; Haggstrom, David A.; Issa, Muta M.; Siddiqui, M. Minhaj; Tosoian, Jeffrey; Schroeck, Florian R.; Medicine, School of Medicine
    Objective: To determine if accurate documentation of bladder cancer risk was associated with a clinician surveillance recommendation that is concordant with AUA guidelines among patients with nonmuscle invasive bladder cancer (NMIBC). Methods: We prospectively collected data from cystoscopy encounter notes from four Department of Veterans Affairs (VA) sites to ascertain whether they included accurate documentation of bladder cancer risk and a recommendation for a guideline-concordant surveillance interval. Accurate documentation was a clinician-recorded risk classification matching a gold standard assigned by the research team. Clinician recommendations were guideline-concordant if the clinician recorded a surveillance interval that was in line with the AUA guideline. Results: Among 296 encounters, 75 were for low-, 98 for intermediate-, and 123 for high-risk NMIBC. 52% of encounters had accurate documentation of NMIBC risk. Accurate documentation of risk was less common among encounters for low-risk bladder cancer (36% vs 52% for intermediate- and 62% for high-risk, P < .05). Guideline-concordant surveillance recommendations were also less common in patients with low-risk bladder cancer (67% vs 89% for intermediate- and 94% for high-risk, P < .05). Accurate documentation was associated with a 29% and 15% increase in guideline-concordant surveillance recommendations for low- and intermediate-risk disease, respectively (P < .05). Conclusion: Accurate risk documentation was associated with more guideline-concordant surveillance recommendations among low- and intermediate-risk patients. Implementation strategies facilitating assessment and documentation of risk may be useful to reduce overuse of surveillance in this group and to prevent unnecessary cost, anxiety, and procedural harms.
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    Integration and evaluation of implementation strategies to improve guideline-concordant bladder cancer surveillance: a prospective observational study
    (Springer Nature, 2025-04-07) Zubkoff, Lisa; Ould Ismail, A. Aziz; Jensen, Laura; Haggstrom, David A.; Kale, Soham; Issa, Muta M.; Tosoian, Jeffrey J.; Siddiqui, Mohummad Minhaj; Bloomquist, Kennedi; Kimball, Elisabeth R.; Zickmund, Susan; Schroeck, Florian R.; Medicine, School of Medicine
    Background: Despite guideline recommendations, our prior work revealed more than half of low-risk bladder cancer patients within the Department of Veterans Affairs (VA) undergo too many surveillance procedures and about a third of high-risk patients do not undergo enough procedures. Thus, we developed and integrated implementation strategies to improve risk-aligned bladder cancer surveillance for the VA. Methods: Prior work used Implementation Mapping to develop nine implementation strategies: change record systems, educational meetings, champions, tailoring, preparing patients to be active participants, external facilitation, remind clinicians, audit & feedback, and a blueprint. We integrated these strategies as improvement approaches across four VA urology clinics. Primary implementation outcomes were qualitatively measured via coding of semi-structured interviews with clinicians and co-occurrence of codes. Implementation outcomes included: appropriateness, acceptability, and feasibility. Exploratory quantitative outcomes included clinicians' recommendations for guideline-concordant bladder cancer surveillance intervals and sustainability. Results: Eleven urologists were interviewed. Co-occurrence analysis of codes across strategies indicated that urologists most commonly reported on the acceptability and appropriateness of changing the record system, preparing patients to be active participants ("surveillance grid"), reminders (i.e., cheat sheet), and educational sessions. We confirmed feasibility of all implementation strategies. Urologists indicated that changing the record system had a high impact, reduced documentation time, and guided resident physicians. Preparing patients to be active participants using the "surveillance grid" was seen as an effective but time-consuming tool. Educational sessions were seen as critical to support implementation. In quantitative analyses, clinicians recommended guideline-concordant surveillance about 65% of the time at baseline for low-risk patients, and this improved to 70% during evaluation. Across all risk levels, the largest improvement was observed at site 2 while site 3 did not improve. All sites sustained use of the changed record system, while sustainability of other strategies was variable. Conclusions: Based on summative interpretation of results, the most appropriate, acceptable, and feasible strategies include changing record systems via a template and educational meetings focused on guideline-concordant surveillance. Future work should assess the impact of the improvement approaches on clinical care processes, particularly on reducing overuse of surveillance procedures among low-risk patients.