Qualitative analysis of barriers to precision oncology within the VHA.

e18760Background: Rapidly expanding knowledge of molecular drivers of cancer helps facilitate effective, targeted cancer therapy (i.e. precision oncology), but research suggests that precision oncology is underused. We conducted a qualitative study of barriers and facilitators of precision oncology use within the Veterans Health Administration (VHA). Methods: We conducted a pragmatic qualitative study involving semi-structured interviews with both patients and providers at VA medical centers with low, medium, and high guideline concordant molecular testing. The interview guide was constructed by a multidisciplinary team of oncologists, qualitative health researchers and patient representatives using modified grounded theory (MGT) and the Theoretical Domains Framework (TDF). Summative and directed content analyses were conducted. Codes for the directed content analysis came from the framework and others evolved iteratively. Consensus-based approaches finalized the codebook. Results: Thirty-three interviews were conducted (17 patient and 16 provider interviews). A total of 1889 unique phrases were identified and categorized into 255 meaningful statement codes. The codes were mapped to 10 TDF domains. The most frequently cited determinants, representing 59% (1110 of 1889 statements) of all coded data, included the domains environmental context and resources, knowledge, and goals. Both patients and providers shared similar goals of improved outcomes and quality of care, but systems barriers were frequently cited impediments to precision oncology use. An additional 27% of codes (510 of 1889) represented the TDF domains of emotions (predominantly patient “fear of genetics” and confidence in providers), memory/attention (task priority in clinic visits), and interpersonal skills (both patient-provider, and interdisciplinary provider-provider). Additional frequently cited determinants, each comprising 6% of coded statements, included social influences (for both providers and patients) and reinforcement (perceived consequences). Conclusions: We identified determinants of precision oncology use at the patient, provider, and system level. Attempts to improve implementation of precision oncology will need to address systems barriers to care, as well as knowledge and patient-provider interactions, but can build on a foundation of shared goals.