Multilevel Veteran-centric Intervention to Improve Precision Oncology

/Abstract Background: Precision oncology (PO), the use of molecular testing to identify tumor specific abnormalities which facilitate targeted therapy, is proven to extend lives and improve quality of life for patients with cancer. Extensive study, however, documents that up to 50% of patients in the VA, especially those with adverse social determinants of health (older age, rural), do not receive guideline recommended PO. Our previous work and others’ established barriers to PO at patient, provider, and facility levels. Significance: Our proposed patient-informed, theory-based multilevel intervention (MLI) to improve PO responds to HSRD’s research priorities (equity, veteran engagement), and VA’s reaffirmed commitment to a learning health system with equal care for rural and aging veterans, codified in the VA Strategic Plan 2022. Innovation and Impact: The overarching aim of the proposal is to improve the quality of oncology care by increasing stakeholder engagement in PO. We are among the first to combine individual level intervention components into a MLI to facilitate the sustainable, equitable use of PO across diverse populations and healthcare settings, and advance implementation understanding with a process evaluation. Specific Aims: Aim 1: Test the effect of a MLI for patients, providers, and facilities on guideline- concordant receipt of PO among patients with colon, lung, and prostate cancer. H1: The MLI will increase the guideline-concordant receipt of molecular testing (H1a) and targeted therapy (H1b) above baseline values at the level of the patient, facility and provider. Aim2: Evaluate mediators and moderators of the effects of the MLI on PO use. H2.1 Constructs of stakeholder engagement (patient activation, provider knowledge, provider belief in capability and organizational support) will function as mediators of the effect of the MLI on PO utilization. H2.2 Facility level factors (rurality, telehealth utilization) will serve as moderators of the effect of the MLI on PO. Aim 3: Conduct a mixed methods process evaluation of the MLI. Objective: Evaluate local site factor associations with implementation success by Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) measures. Methodology: Building on our previous analyses, and the Theoretical Domains Framework we designed a mixed-methods type I hybrid effectiveness-implementation study. The MLI will be applied to veterans with advanced cancers of the colon, lung, and prostate at 8 sites, chosen to represent diversity at the level of rurality, geographic region, cancer volume, and mode of delivery (virtual/in-person). The patient intervention is a 5 minute tablet based educational module. The provider intervention is a 45 minute academic detailing session, as well as individualized audit and feedback on practice patterns. The facility level intervention is a previously piloted integration of PO ordering, interdepartmental communication, and results return into the primary electronic medical record via a consult function. The primary efficacy outcomes is the rate of molecular testing/eligible veterans. Validated measures will be used for stakeholder engagement. The process evaluation employs a mixed methods approach based in the RE-AIM framework. The statistical design is a randomized stepped-wedge trial over 2.5 years which retains control data from across all sites. Next Steps/Implementation: All components of the intervention, designed in partnership with the VA National Oncology Program Office and National Precision Oncology Program, are prepared for widespread dissemination throughout the VAMC’s, in the event that the trial demonstrates benefit. The engagement study is designed to understand the processes underlying effectiveness of the MLI. The process evaluation uses established techniques to refine the intervention for more effective dissemination. Project Number: 5I01HX003729-02 | Fiscal Year: 2026 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Daniel Becker | Institution: VA MEDICAL CENTER, NEW YORK, NY | Activity Code: I01 | Study Section: HSR-1 Health Care and Clinical Management[HSR1] View on NIH RePORTER: https://reporter.nih.gov/project-details/11282605