Data-driven approach to implementation mapping for the selection of implementation strategies: a case example for risk-aligned bladder cancer surveillance.

BACKGROUND: Implementation Mapping is an organized method to select implementation strategies. However, there are 73 Expert Recommendations for Implementing Change (ERIC) strategies. Thus, it is difficult for implementation scientists to map all potential strategies to the determinants of their chosen implementation science framework. Prior work using Implementation Mapping employed advisory panels to select implementation strategies. This article presents a data-driven approach to implementation mapping, in which we systematically evaluated all 73 ERIC strategies using the Tailored Implementation for Chronic Diseases (TICD) framework. We illustrate our approach using implementation of risk-aligned bladder cancer surveillance as a case example. METHODS: We developed objectives based on previously collected qualitative data organized by TICD determinants, i.e., what needs to be changed to achieve more risk-aligned surveillance. Next, we evaluated all 73 ERIC strategies, excluding those that were not applicable to our clinical setting. The remaining strategies were mapped to the objectives using data visualization techniques to make sense of the large matrices. Finally, we selected strategies with high impact, based on (1) broad scope, defined as a strategy addressing more than the median number of objectives, (2) requiring low or moderate time commitment from clinical teams, and (3) evidence of effectiveness from the literature. RESULTS: We identified 63 unique objectives. Of the 73 ERIC strategies, 45 were excluded because they were not applicable to our clinical setting (e.g., not feasible within the confines of the setting, not appropriate for the context). Thus, 28 ERIC strategies were mapped to the 63 objectives. Strategies addressed 0 to 26 objectives (median 10.5). Of the 28 ERIC strategies, 10 required low and 8 moderate time commitments from clinical teams. We selected 9 strategies based on high impact, each with a clearly documented rationale for selection. CONCLUSIONS: We enhanced Implementation Mapping via a data-driven approach to the selection of implementation strategies. Our approach provides a practical method for other implementation scientists to use when selecting implementation strategies and has the advantage of favoring data-driven strategy selection over expert opinion.

Determinants of Risk-Aligned Bladder Cancer Surveillance-Mixed-Methods Evaluation Using the Tailored Implementation for Chronic Diseases Framework.

PURPOSE: For many patients with cancer, the frequency of surveillance after primary treatment depends on the risk for cancer recurrence or progression. Lack of risk-aligned surveillance means too many unnecessary surveillance procedures for low-risk patients and not enough for high-risk patients. Using bladder cancer as an example, we examined whether practice determinants differ between Department of Veterans Affairs sites where risk-aligned surveillance was more (risk-aligned sites) or less common (need improvement sites). METHODS: We used our prior quantitative data to identify two risk-aligned sites and four need improvement sites. We performed semistructured interviews with 40 Veterans Affairs staff guided by the Tailored Implementation for Chronic Diseases framework that were deductively coded. We integrated quantitative data (risk-aligned site v need improvement site) and qualitative data from interviews, cross-tabulating salient determinants by site type. RESULTS: There were 14 participants from risk-aligned sites and 26 participants from need improvement sites. Irrespective of site type, we found a lack of knowledge on guideline recommendations. Additional salient determinants at need improvement sites were a lack of resources ("the next available without overbooking is probably seven to eight weeks out") and an absence of routines to incorporate risk-aligned surveillance ("I have my own guidelines that I've been using for 35 years"). CONCLUSION: Knowledge, resources, and lack of routines were salient barriers to risk-aligned bladder cancer surveillance. Implementation strategies addressing knowledge and resources can likely contribute to more risk-aligned surveillance. In addition, reminders for providers to incorporate risk into their surveillance plans may improve their routines.

Breast implant-associated anaplastic large-cell lymphoma: long-term follow-up of 60 patients.

PURPOSE: Breast implant-associated anaplastic large-cell lymphoma (ALCL) is a recently described clinicopathologic entity that usually presents as an effusion-associated fibrous capsule surrounding an implant. Less frequently, it presents as a mass. The natural history of this disease and long-term outcomes are unknown. PATIENTS AND METHODS: We reviewed the literature for all published cases of breast implant-associated ALCL from 1997 to December 2012 and contacted corresponding authors to update clinical follow-up. RESULTS: The median overall survival (OS) for 60 patients was 12 years (median follow-up, 2 years; range, 0-14 years). Capsulectomy and implant removal was performed on 56 of 60 patients (93%). Therapeutic data were available for 55 patients: 39 patients (78%) received systemic chemotherapy, and of the 16 patients (28%) who did not receive chemotherapy, 12 patients opted for watchful waiting and four patients received radiation therapy alone. Thirty-nine (93%) of 42 patients with disease confined by the fibrous capsule achieved complete remission, compared with complete remission in 13 (72%) of 18 patients with a tumor mass. Patients with a breast mass had worse OS and progression-free survival (PFS; P = .052 and P = .03, respectively). The OS or PFS were similar between patients who received and did not receive chemotherapy (P = .44 and P = .28, respectively). CONCLUSION: Most patients with breast implant-associated ALCL who had disease confined within the fibrous capsule achieved complete remission. Proper management for these patients may be limited to capsulectomy and implant removal. Patients who present with a mass have a more aggressive clinical course that may be fatal, justifying cytotoxic chemotherapy in addition to removal of implants.

The role of beta-catenin in chronic myeloproliferative disorders.

The goal of the current study is to evaluate the role of beta-catenin in chronic myeloproliferative disorders. Expression of beta-catenin was analyzed by immunohistochemistry in formalin-fixed decalcified bone marrow biopsy specimens from 52 chronic myeloproliferative disorder cases and 6 nonchronic myeloproliferative disorder bone marrows as controls. The frequency of moderate to strong beta-catenin staining of megakaryocytes was significantly higher in polycythemia vera cases and in essential thrombocythemia cases than in chronic myelogenous leukemia cases (polycythemia vera versus chronic myelogenous leukemia, P = .002345, Fisher exact; and essential thrombocythemia versus chronic myelogenous leukemia, P = .002288), chronic idiopathic myelofibrosis cases (polycythemia vera versus chronic idiopathic myelofibrosis, P = .006707 and essential thrombocythemia versus chronic idiopathic myelofibrosis, P = .006932) or control cases (polycythemia vera versus control, P = .010489 and essential thrombocythemia versus control, P = .0113120). The erythroid and myeloid lineages showed absent to weak beta-catenin staining in most cases. In conclusion, these results indicate that the Wnt/beta-catenin signaling pathway may have a role in megakaryocytopoiesis in polycythemia vera and essential thrombocythemia. In addition, beta-catenin may be a useful marker for differentiating polycythemia vera and essential thrombocythemia from other types of chronic myeloproliferative disorders.

Essential thrombocythemia: a review of diagnostic and pathologic features.

CONTEXT: Essential thrombocythemia (ET) is a chronic myeloproliferative disorder (CMPD) characterized predominately by thrombocytosis and abnormal megakaryocyte proliferation. The current diagnostic criteria require a combination of clinical, histologic, and cytogenetic data. The diagnosis relies largely on exclusion of other causes of thrombocytosis. OBJECTIVE: Describe historical, clinical, and laboratory features of ET in order to understand, clarify, and more accurately diagnose this entity. DATA SOURCES: Review contemporary and historical literature on ET and other causes of thrombocytosis. CONCLUSIONS: ET is a relatively indolent and often asymptomatic CMPD that is characterized primarily by a sustained elevation in platelets > or = 600 x 10(3)/microL (> or = 600 x 10(9)/L), proliferating enlarged and hyperlobated megakaryocytes, and minimal to absent bone marrow fibrosis. Significant changes and revisions to the diagnostic requirements and criteria for ET have occurred during the last 30 years. Recently, a mutation in the Janus kinase 2 (JAK2) gene has been found in a significant number of cases of ET and other CMPDs. In up to 57% of ET cases, a mutation in the JAK2 gene can be detected. In the absence of a JAK2 mutation and features of another CMPD, the diagnosis of ET remains a diagnosis of exclusion after other causes of thrombocytosis have been excluded.

Composite lymphocyte-rich Hodgkin lymphoma and peripheral T-cell lymphoma associated with Epstein-Barr virus: a case report and review of the literature.

We report a case of a 65-year-old black man with combined Hodgkin lymphoma and T-cell lymphoma. The patient presented with diffuse lymphadenopathy, fever, weight loss, and night sweats. Subsequent biopsy of an axillary lymph node revealed a composite lymphoma composed of classic Hodgkin lymphoma and a peripheral T-cell lymphoma. A needle biopsy of the liver also showed involvement by the composite lymphoma. In situ hybridization studies revealed positive Epstein-Barr virus in Reed-Sternberg cells. Development of T-cell lymphoma following chemotherapy for Hodgkin lymphoma has been reported, but synchronous composite occurrence of both lesions is very rare. Furthermore, this is the first report of such occurrence in a black patient. We present a review of the literature and a discussion of the potential pathophysiologic role of Epstein-Barr virus in the early stages of T-cell lymphomagenesis.