“I’m Putting My Trust in Their Hands”

Motivators, Barriers, and Facilitators to Choosing Care in VA Facilities Versus VA-Purchased Care

Many Veterans receive Department of Veterans Affairs (VA)-purchased care from non-VA facilities but little is known about factors that Veterans consider for this choice. Between May 2020 and August 2021, we surveyed VA-purchased care-eligible VA patients about barriers and facilitators to choosing where to receive care. We examined the association between travel time to their VA facility and their choice of VA-purchased care (VA-paid health care received in non-VA settings) versus VA facility and whether this association was modified by distrust. We received 1,662 responses and 692 (42%) chose a VA facility. Eighty percent reported quality care was in their top three factors that influenced their decision. Respondents with the highest distrust and who lived >1 hr from the nearest VA facility had the lowest predicted probability (PP) of choosing VA (PP 15%; 95% confidence interval: 10%-20%). Veterans value quality of care. VA and other health care systems should consider patient-centered ways to improve and publicize quality and reduce distrust.

Patient-reported outcome and experience domains for diagnostic excellence: a scoping review to inform future measure development

PURPOSE

"Diagnostic excellence," as a relatively new construct centered on the diagnostic process and its health-related outcomes, can be refined by patient reporting and its measurement. We aimed to explore the scope of patient-reported outcome (PRO) and patient-reported experience (PRE) domains that are diagnostically relevant, regardless of the future diagnosed condition, and to review the state of measurement of these patient-reported domains.

METHODS

We conducted an exploratory analysis to identify these domains by employing a scoping review supplemented with internal expert consultations, 24-member international expert convening, additional environmental scans, and the validation of the domains' diagnostic relevance via mapping these onto patient diagnostic journeys. We created a narrative bibliography of the domains illustrating them with existing measurement examples.

RESULTS

We identified 41 diagnostically relevant PRO and PRE domains. We classified 10 domains as PRO, 28 as PRE, and three as mixed PRO/PRE. Among these domains, 19 were captured in existing instruments, and 20 were captured only in qualitative studies. Two domains were conceptualized during this exploratory analysis with no examples identified of capturing these domains. For 27 domains, patients and care partners report on a specific encounter; for 14 domains, reporting relates to an entire diagnostic journey over time, which presents particular measurement opportunities and challenges.

CONCLUSION

The multitude of PRO and PRE domains, if measured rigorously, would allow the diagnostic excellence construct to evolve further and in a manner that is patient-centered, prospectively focused, and concentrates on effectiveness and efficiency of diagnostic care on patients' well-being.

Patient Lung Cancer Screening Decisions and Environmental and Psychosocial Factors

Importance

Screening for lung cancer using low-dose computed tomography is associated with reduced lung cancer-specific mortality, but uptake is low in the US; understanding how patients make decisions to engage with lung cancer screening is critical for increasing uptake. Prior research has focused on individual-level psychosocial factors, but environmental factors (eg, historical contexts that include experiencing racism) and modifying factors-those that can be changed to make it easier or harder to undergo screening-also likely affect screening decisions.

Objective

To investigate environmental, psychosocial, and modifying factors influencing lung cancer screening decision-making and develop a conceptual framework depicting relationships between these factors.

Design, Setting, and Participants

This multimethod qualitative study was conducted from December 2021 to June 2022 using virtual semistructured interviews and 4 focus groups (3-4 participants per group). All participants met US Preventive Services Task Force eligibility criteria for lung cancer screening (ie, age 50-80 years, at least a 20 pack-year smoking history, and either currently smoke or quit within the past 15 years). Screening-eligible US participants were recruited using an online panel.

Main Outcomes and Measures

Key factors influencing screening decisions (eg, knowledge, beliefs, barriers, and facilitators) were the main outcome. A theory-informed, iterative inductive-deductive approach was applied to analyze data and develop a conceptual framework summarizing results.

Results

Among 34 total participants (interviews, 20 [59%]; focus groups, 14 [41%]), mean (SD) age was 59.1 (4.8) years and 20 (59%) identified as female. Half had a household income below $20 000 (17 [50%]). Participants emphasized historical and present-day racism as critical factors contributing to mistrust of health care practitioners and avoidance of medical procedures like screening. Participants reported that other factors, such as public transportation availability, also influenced decisions. Additionally, participants described psychosocial processes involved in decisions, such as perceived screening benefits, lung cancer risk appraisal, and fear of a cancer diagnosis or harmful encounters with practitioners. In addition, participants identified modifying factors (eg, insurance coverage) that could make receiving screening easier or harder.

Conclusions and Relevance

In this qualitative study of patient lung cancer screening decisions, environmental, psychosocial, and modifying factors influenced screening decisions. The findings suggest that systems-level interventions, such as those that help practitioners understand and discuss patients' prior negative health care experiences, are needed to promote effective screening decision-making.

Addressing the communication needs of cancer patients for Magnetic Resonance Imaging (MRI) investigations-A phenomenological study on the experiences of MRI radiographers

INTRODUCTION

A higher demand in MRI services could increase the pressure on MRI departments to increase scanning efficiency. This presents the risk of downplaying person-centred care especially for cancer patients with increased communication needs that result from anxiety associated with the nature of their disease. This study explored the experiences of MRI radiographers in addressing the communication needs of cancer patients attending for MRI examinations.

METHODS

The study adopted a descriptive phenomenological methodology. Single contact interviews were conducted on eight MRI specialist radiographers, and these were recorded and transcribed using Microsoft Teams conferencing platform. Thematic analysis of the transcribed data was done through an inductive approach, breaking down the data into meaningful codes and thereafter, into themes and sub-themes.

RESULTS

Common themes generated from the interview data included: identified communication needs, approach to communication needs, support for radiographers and factors affecting communication. Experiences of MRI radiographers indicated increased communication needs in anxious cancer patients and approaches adopted in addressing these were mainly through listening and use of empathetic gestures. Some radiographers admitted to using "blocking" strategies to avoid being drawn into emotionally exhausting conversations. Both intrinsic factors such as radiographers' personality and experience; and extrinsic factors such as time constraints, demanding workload, inadequate staffing, and skill mix were noted to influenced MRI radiographers in addressing these communication needs.

CONCLUSION

Cancer patients can present with communication needs due to anxieties related to their disease. For the radiographer to deal with these needs, adequate support is needed, and necessary steps taken to address the identified influencing factors.

IMPLICATIONS FOR PRACTICE

MRI departments should encourage enabling environment and services that address communication needs of patients with cancer.

Lung cancer screening program factors that influence psychosocial outcomes: A systematic review

OBJECTIVES

Lung cancer screening (LCS) programs are being designed and implemented globally. Early data suggests that the psychosocial impacts of LCS are influenced by program factors, but evidence synthesis is needed. This systematic review aimed to elucidate the impact of service-level factors on psychosocial outcomes to inform optimal LCS program design and future implementation.

METHODS

Four databases were searched from inception to July 2023. Inclusion criteria were full-text articles published in English that reported an association between any program factors and psychosocial outcomes experienced during LCS. Study quality was appraised, and findings were synthesised narratively.

RESULTS

Thirty-two articles were included; 29 studies were assessed at high or moderate risk of bias. Study designs were RCT (n = 3), pre-post (n = 6), cross-sectional (n = 12), mixed-methods (n = 1), and qualitative (n = 10) studies, and conducted primarily in the USA (n = 25). Findings suggested that targeted interventions can improve smoking-related or decisional psychosocial outcomes (e.g., smoking cessation interventions increase readiness/motivation to quit) but impacts of interventions on other psychological outcomes were varied. There was limited evidence reporting association between service delivery components and psychological outcomes, and results suggested moderation by individual aspects (e.g., expectation of results, baseline anxiety). Opportunities for discussion were key in reducing psychological harm.

CONCLUSIONS

Certain program factors are reportedly associated with psychosocial impacts of LCS, but study heterogeneity and quality necessitate more real-world studies. Future work should examine (a) implementation of targeted interventions and high-value discussion during LCS, and (b) optimal methods and timing of risk and result communication, to improve psychosocial outcomes while reducing time burden for clinicians.

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

Exploring the Relationship Between Intolerance of Uncertainty and Trust in Physicians from Spousal and Parent-Child Perspectives

Objective

The present study aimed to probe the intergenerational transmission of intolerance of uncertainty (IU) and trust in physicians. Besides, through the actor-partner interdependence model (APIM), the predictive effect of parents' IU on their own and their spouses' trust in physicians was examined. A mediation model was further constructed to probe the mechanisms by which parents' IU affects children's trust in physicians.

Methods

The Intolerance of Uncertainty Scale-12 (IUS-12) and the Wake Forest Physician Trust Scale (WFPTS) were employed to conduct the questionnaire survey among 384 families (each family with a father, mother, and one child).

Results

IU and trust in physicians were found to be intergenerationally transmitted. The results of the APIM analyses showed that fathers' total IUS-12 scores negatively predicted their own (β = -0.419, p < 0.01) and mothers' (β = -0.235, p < 0.01) total WFPTS scores. Mothers' total IUS-12 scores negatively predicted their own (β = -0.353, p < 0.01) and fathers' (β = -0.138, p = 0.017) total WFPTS scores. The results of mediation analyses indicated that parents' total WFPTS scores and children's total IUS-12 scores mediated the effect of parents' total IUS-12 scores on children's total WFPTS scores.

Conclusion

The public's IU is a crucial influencing factor of their trust in physicians. Besides, the IU between couples and between parents and children could be mutually affected. On the one hand, husbands' IU could affect their own and their wives' trust in physicians, and vice versa. On the other hand, parents' IU and trust in physicians could affect their children's IU and trust in physicians, respectively.

Interpersonal risk communication matters more than media risk communication in its impact on individuals' trust and preventive behaviors during COVID-19

A cross-sectional survey study from 1496 respondents was conducted to investigate how interpersonal risk communication and media risk communication foster individuals' interpersonal trust and trust in scientists during the ongoing COVID-19 pandemic. Findings reveal that interpersonal risk communication is significantly related to interpersonal trust and trust in scientists, but have no direct association with preventive behaviors. Media risk communication is significantly associated with preventive behaviors and increases individuals' trust in scientists while having no effect on interpersonal trust. Preventive behaviors are significantly influenced by both interpersonal trust and trust in scientists. In addition, trust mediated the association between risk communication and preventive behaviors.

"It's a decision I have to make": Patient perspectives on smoking and cessation after lung cancer screening decisions

Few studies exist showing that involvement in lung cancer screening (LCS) leads to a change in rates of cigarette smoking. We investigated LCS longitudinally to determine whether teachable moments for smoking cessation occur downstream from the initial provider-patient LCS shared decision-making discussion and self-reported effects on smoking behaviors. We performed up to two successive semi-structured interviews to assess the experiences of 39 individuals who formerly or currently smoked cigarettes who underwent LCS decision-making discussions performed during routine care from three established US medical center LCS programs.

The majority of those who remembered hearing about the importance of smoking cessation after LCS-related encounters did not report communication about smoking influencing their motivation to quit or abstain from smoking, including patients who were found to have pulmonary nodules. Patients experienced little distress related to LCS discussions. Patients reported that there were other, more significant, reasons for quitting or abstinence. They recommended clinicians continue to ask about smoking at every clinical encounter, provide information comparing the benefits of LCS with those of quitting smoking, and have clinicians help them identify triggers or other motivators for improving smoking behaviors. Our findings suggest that there may be other teachable moment opportunities outside of LCS processes that could be utilized to motivate smoking reduction or cessation, or LCS processes could be improved to integrate cessation resources.

Bringing personal perspective elicitation to the heart of shared decision-making: A scoping review

OBJECTIVES

Proponents of shared decision-making (SDM) advocate the elicitation of the patient's perspective. This scoping review explores if, and to what extent, the personal perspectives of patients are elicited during a clinical encounter, as part of a SDM process. We define personal perspective elicitation (PPE) as: the disclosure (either elicited by the clinician or spontaneously expressed by the patient) of information related to the patient's personal preferences, values and/or context.

METHODS

A search was conducted in five literature databases from inception dates up to July 2020, to identify empirical studies about SDM (with/without SDM instrument).

RESULTS

The search identified 4562 abstracts; 263 articles were read in full text, resulting in 99 included studies. Studies reported low levels of PPE. Integration of personal perspectives into the conversation or a future care plan was largely absent. The majority of the discussed content related to physical health, while social and psychological topics were mostly unaddressed.

CONCLUSIONS

PPE occurs on a very low level in efforts to achieve SDM according to evaluation studies.

PRACTICE IMPLICATIONS

PPE is advocated but rarely achieved in SDM evaluation studies. Causes should be identified, followed by designing interventions to improve this aspect of SDM.

Lung cancer screening at the VA: Past, present and future

Lung cancer is responsible for more deaths annually in the United States than breast, prostate and colon cancers combined. Lung cancer screening with annual low-dose computed tomography reduces lung cancer mortality in high-risk patients through early detection. The incidence of lung cancer is higher in the veteran population compared to the general population due, in part, to the prevalence of tobacco use. Early detection of lung cancer is therefore an important goal of the Veterans Health Administration (VHA), the largest integrated health care system in the United States. The following will review previous and current initiatives undertaken by the VHA to implement and expand access to lung cancer screening and will highlight target areas of interest to improve uptake and quality of lung cancer screening. Through these initiatives and programs, the VHA aims to provide high quality and equitable access to lung cancer screening for all Veterans that incorporates research that will improve outcomes and potentially inform and optimize the practice of Lung cancer screening across the United States.

Screening for Lung Cancer: CHEST Guideline and Expert Panel Report

BACKGROUND

Low-dose chest CT screening for lung cancer has become a standard of care in the United States, in large part because of the results of the National Lung Screening Trial (NLST). Additional evidence supporting the net benefit of low-dose chest CT screening for lung cancer, and increased experience in minimizing the potential harms, has accumulated since the prior iteration of these guidelines. Here, we update the evidence base for the benefit, harms, and implementation of low-dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not.

METHODS

Approved panelists reviewed previously developed key questions using the Population, Intervention, Comparator, Outcome format to address the benefit and harms of low-dose CT screening, and key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. Reference lists from relevant retrievals were searched, and additional papers were added. Retrieved references were reviewed for relevance by two panel members. The quality of the evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analyses were performed when enough evidence was available. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and ungraded statements were drafted, voted on, and revised until consensus was reached.

RESULTS

The systematic literature review identified 75 additional studies that informed the response to the 12 key questions that were developed. Additional clinical questions were addressed resulting in seven graded recommendations and nine ungraded consensus statements.

CONCLUSIONS

Evidence suggests that low-dose CT screening for lung cancer can result in a favorable balance of benefit and harms. The selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen-detected findings, and the effectiveness of smoking cessation interventions can impact this balance.

"It's Really Like Any Other Study": Rural Radiology Facilities Performing Low-Dose Computed Tomography for Lung Cancer Screening

RATIONALE

The majority of eligible people have not been screened for lung cancer. There is emerging evidence that there are location-based disparities applicable to lung cancer screening.

OBJECTIVE

Describe lung cancer screening radiologic services in rural Oregon and understand the barriers and facilitators to implementation of lung cancer screening using LDCT.

METHODS

A mixed-methods descriptive study utilizing surveys and semi-structured interviews of key informants. We approached representatives from all 37 small and rural hospitals in Oregon. We purposively interviewed key informants from a sub-set based on LDCT implementation outcomes.

RESULTS

We surveyed representatives from 29 radiology facilities and qualitatively interviewed 18 key informants from 19 facilities (representing 12 health care systems). Among the surveyed radiology facilities, 59% were performing LDCT for lung cancer screening. Key informants reported that facilities which performed this service were often motivated by community needs, less by financial gain or evidence strength and all described the importance of a champion. Key informants described that implementing lung cancer screening programmatic components that were within their normal scope of practice (e.g. specifying the LDCT parameters) were burdensome to establish but were surmountable barriers. Most informants reported they did not perform other components of high-quality programs (e.g. ensuring adherence to recommended follow-up testing) and suggested these steps were important but the responsibility of primary care providers.

CONCLUSIONS

Many rural hospital facilities in Oregon offer LDCT for lung cancer screening, but do not perform all the recommended components of a screening program. Disparities in lung cancer screening utilization and adherence are unlikely to be solved by an exclusive focus at the radiology facility level and may require additional interventions at the primary care level.

Promoting Clinical Conversations about Lung Cancer Screening: Exploring the Role of Perceived Online Social Support

The perceived availability of online social support may contribute to patient-provider conversations about lung cancer screening. This study examines how the perceived availability of instrumental and emotional online social support is associated with patient-provider communication about lung cancer screening among adults who meet U.S. Preventive Services Taskforce (USPSTF) eligibility criteria and live with a COPD diagnosis. In April 2018, 575 adults completed an online survey after being recruited from a large southeastern academic medical center's broad research registry and website listing. Nearly half of the participants were 55-to-80 years old (41%), a current or former smoker who had quit smoking within the past 15 years (42%), and reported a smoking prevalence of 30 pack years or more (PPY; 41%). Results demonstrate that having a COPD diagnosis, identifying as male, and being a current or former tobacco smoker resulted in greater odds of having a clinical conversation about lung cancer screening. Conversely, meeting the 30 PPY smoking and 55-to-80 age thresholds lowered the odds of having these conversations. A high degree of instrumental and emotional online social support was associated with a greater incidence of annual patient-provider conversations about screening. This combination of perceived online social support was especially useful for patients with COPD.