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Ortmeyer K, Ma GX, Kaiser LR, Erkmen C. Effective Educational Approaches to Training Physicians About Lung Cancer Screening. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:52-57. [PMID: 32504361 PMCID: PMC7718418 DOI: 10.1007/s13187-020-01784-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In 2013, the U.S. Preventative Services Task Force recommended low-dose computed tomography (LDCT) for lung cancer screening (LCS) after a national trial demonstrated a 20% reduction in lung cancer mortality with LDCT. Implementation of LCS employing LDCT depends heavily on physician education regarding multiple factors, including eligibility criteria, potential benefits and harms, and shared decision-making. To date, there are no studies of educational approaches for teaching physicians about LCS. This study aims to assess the feasibility and effectiveness of implementing an interactive, group-based learning (GBL) curriculum to teach physicians about LCS. A prospective study was conducted at two nearby institutions from 2017 to 2019 comparing GBL with a lecture format as measured by total knowledge about LCS, acceptability of the educational format, and ease of implementation. We surveyed participants regarding total knowledge and format acceptance. Results were compared to determine whether GBL is an effective and feasible educational strategy for LDCT and LCS education. Residents and faculty participating in GBL demonstrated greater total knowledge compared with residents and faculty participating in the lecture format. Participants in both cohorts preferred a mix of GBL and lecture formats. All participants believed that GBL facilitates implementation of LCS better than lecture-based learning. GBL is an effective and feasible approach for educating physicians about LCS, though it is more time- and resource-intensive than a lecture approach. However, healthcare providers believe GBL will facilitate implementation of LCS more than lectures.
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Affiliation(s)
- Katherine Ortmeyer
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Grace X Ma
- Center for Asian Health, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Larry R Kaiser
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Cherie Erkmen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
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Changes in Physician Knowledge, Attitudes, Beliefs, and Practices regarding Lung Cancer Screening. Ann Am Thorac Soc 2020; 16:1065-1069. [PMID: 31075047 DOI: 10.1513/annalsats.201812-867rl] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wilcox SR, Richards JB, Stevenson EK. Association Between Do Not Resuscitate/Do Not Intubate Orders and Emergency Medicine Residents’ Decision Making. J Emerg Med 2020; 58:11-17. [PMID: 31708311 DOI: 10.1016/j.jemermed.2019.09.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Research has shown that do not resuscitate (DNR) and do not intubate (DNI) orders may be construed by physicians to be more restrictive than intended by patients. Previous studies of physicians found that DNR/DNI orders are associated with being less willing to provide invasive care. OBJECTIVES The purpose of this study was to assess the influence of code status on emergency residents' decision-making regarding offering invasive procedures for those patients with DNR/DNI compared with their full code counterparts. METHODS We conducted a nationwide survey of emergency medicine residents using an instrument of 4 clinical vignettes involving patients with serious illnesses. Two versions of the survey, survey A and survey B, alternated the DNR/DNI and full code status for the vignettes. Residency leaders were contacted in August 2018 to distribute the survey to their residents. RESULTS Three hundred and three residents responded from across the country. The code status was strongly associated with decisions to intubate or perform CPR and influenced the willingness to offer other invasive procedures. DNR/DNI status was associated with less frequent willingness to place central venous catheters (88.2% for DNR/DNI vs. 97.2% for full code, p < 0.001), admit patients to the intensive care unit (89.9% vs. 99.0%, p < 0.001), offer dialysis (79.3% vs. 98.0%, p < 0.001), and surgical consultation (78.7% vs. 94.2%, p < 0.001). CONCLUSIONS In a nationwide survey, emergency medicine residents were less willing to provide invasive procedures for patients with DNR/DNI status, including the placement of central venous catheters, admission to the intensive care unit, and consultation for dialysis and surgery.
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Henderson LM, Marsh MW, Benefield TS, Jones LM, Reuland DS, Brenner AT, Goldstein AO, Molina PL, Maygarden SJ, Rivera MP. Opinions and Practices of Lung Cancer Screening by Physician Specialty. N C Med J 2019; 80:19-26. [PMID: 30622199 DOI: 10.18043/ncm.80.1.19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In response to the National Lung Screening Trial, numerous professional organizations published guidelines recommending annual lung cancer screening with low-dose computed tomography (LDCT) for high-risk patients. Prior studies found that physician attitudes and knowledge about lung cancer screening directly impacts the number of screening exams ordered.METHODS In 2015, we surveyed 34 pulmonologists and 186 primary care providers (PCPs) to evaluate opinions and practices of lung cancer screening in a large academic medical center. We compared PCP and pulmonologist responses using t-tests and χ2 tests.RESULTS The overall survey response rate was 40% (39% for PCPs and 50% for pulmonologists). Pulmonologists were more likely than PCPs to report lung cancer screening as beneficial for patients (88.2% versus 37.7%, P < .0001) and as being cost-effective (47.1% versus 14.3%, P = .02). More pulmonologists (76%) reported ordering a LDCT for screening in the past 12 months compared to PCPs (41%, P = .012). Pulmonologists and PCPs reported similar barriers to referring patients for lung cancer screening, including patient costs (82.4% versus 77.8%), potential for emotional harm (58.8% versus 58.3%), high false positive rate (47.1% versus 69.4%), and likelihood for medical complications (47.1% versus 59.7%).LIMITATIONS Our results are generalizable to academic medical centers and responses may be susceptible to recall bias, non-response bias, and social desirability bias.CONCLUSION We found significant differences in opinions and practices between PCPs and pulmonologists regarding lung cancer screening referrals and perceived benefits. As lung cancer screening continues to emerge in clinical practice, it is important to understand these differences across provider specialty to ensure screening is implemented and offered to patients appropriately.
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Affiliation(s)
- Louise M Henderson
- associate professor, Department of Radiology; Adjunct Associate Professor, Department of Epidemiology; Member, Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill, North Carolina
| | - Mary W Marsh
- research associate, Department of Radiology, The University of North Carolina, Chapel Hill, North Carolina
| | - Thad S Benefield
- statistician, Department of Radiology, The University of North Carolina, Chapel Hill, North Carolina
| | - Laura M Jones
- research associate, Department of Radiology, The University of North Carolina, Chapel Hill, North Carolina
| | - Daniel S Reuland
- professor, Department of Medicine, Division of General Medicine & Clinical Epidemiology; Member, Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill, North Carolina
| | - Alison T Brenner
- assistant professor, Department of Medicine, Division of General Medicine & Clinical Epidemiology; Member, Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill, North Carolina
| | - Adam O Goldstein
- professor, Department of Family Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - Paul L Molina
- professor, Department of Radiology, The University of North Carolina, Chapel Hill, North Carolina
| | - Susan J Maygarden
- professor, Department of Pathology and Laboratory Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - M Patricia Rivera
- professor, Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine; Member, Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill, North Carolina
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Do doctors understand the test characteristics of lung cancer screening? Wien Klin Wochenschr 2018; 130:238-246. [PMID: 29372409 DOI: 10.1007/s00508-017-1305-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 12/13/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Screening for lung cancer with a low-dose computed tomography (CT) scan is estimated to prevent 3 deaths per 1000 individuals at high risk; however, false positive results and radiation exposure are relevant harms and deserve careful consideration. Screening candidates can only make an autonomous decision if doctors correctly inform them of the pros and cons of the method; therefore, this study aimed to evaluate whether doctors understand the test characteristics of lung cancer screening. METHODS In a randomized trial 556 doctors (members of the Austrian Respiratory Society) were invited to answer questions regarding lung cancer screening based on online case vignettes. Half of the participants were randomized to the group 'solutions provided' and received the correct solutions in advance. The group 'solutions withheld' had to rely on prior knowledge or estimates. The primary endpoint was the between-group difference in the estimated number of deaths preventable by screening. Secondary endpoints were the between-group differences in the prevalence of lung cancer, prevalence of a positive screening results, sensitivity, specificity, positive predictive value, and false negative rate. Estimations were also compared with current data from the literature. RESULTS The response rate was 29% in both groups. The reduction in the number of deaths due to screening was overestimated six-fold (95% confidence interval CI: 4-8) compared with the actual data, and there was no effect of group allocation. Providing the correct solutions to doctors had no systematic effect on their answers. CONCLUSION Doctors poorly understand the test characteristics of lung cancer screening. Providing the correct solutions in advance did not improve the answers. Continuing education regarding lung cancer screening and the interpretation of test characteristics may be a simple remedy. CLINICAL TRIAL REGISTRATION Clinical trial registered with www.clinicaltrials.gov (NCT02542332).
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Henderson LM, Jones LM, Marsh MW, Brenner AT, Goldstein AO, Benefield TS, Greenwood-Hickman MA, Molina PL, Rivera MP, Reuland DS. Opinions, practice patterns, and perceived barriers to lung cancer screening among attending and resident primary care physicians. Risk Manag Healthc Policy 2018; 10:189-195. [PMID: 29403320 PMCID: PMC5784747 DOI: 10.2147/rmhp.s143152] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The US Preventive Services Task Force recommended annual lung cancer screening with low-dose computed tomography (LDCT) for high-risk patients in December 2013. We compared lung cancer screening-related opinions and practices among attending and resident primary care physicians (PCPs). Methods In 2015, we conducted a 23-item survey among physicians at a large academic medical center. We surveyed 100 resident PCPs (30% response rate) and 86 attending PCPs (49% response rate) in Family Medicine and Internal Medicine. The questions focused on physicians’ opinions, knowledge of recommendations, self-reported practice patterns, and barriers to lung cancer screening. In 2015 and 2016, we compared responses among attending versus resident PCPs using chi-square/Fisher’s exact tests and 2-samples t-tests. Results Compared with resident PCPs, attending PCPs were older (mean age =47 vs 30 years) and more likely to be male (54% vs 37%). Over half of both groups concurred that inconsistent recommendations make deciding whether or not to screen difficult. A substantial proportion in both groups indicated that they were undecided about the benefit of lung cancer screening for patients (43% attending PCPs and 55% resident PCPs). The majority of attending and resident PCPs agreed that barriers to screening included limited time during patient visits (62% and 78%, respectively), cost to patients (74% and 83%, respectively), potential for complications (53% and 70%, respectively), and a high false-positive rate (67% and 73%, respectively). Conclusion There was no evidence to suggest that attending and resident PCPs had differing opinions about lung cancer screening. For population-based implementation of lung cancer screening, physicians and trainees will need resources and time to address the benefits and harms with their patients.
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Affiliation(s)
- Louise M Henderson
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | - Laura M Jones
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | - Mary W Marsh
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | - Alison T Brenner
- Department of Medicine.,The University of North Carolina Lineberger Comprehensive Cancer Center
| | - Adam O Goldstein
- Department of Family Medicine, The University of North Carolina, Chapel Hill, NC
| | - Thad S Benefield
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | | | - Paul L Molina
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | | | - Daniel S Reuland
- Department of Medicine.,The University of North Carolina Lineberger Comprehensive Cancer Center
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Khairy M, Duong DK, Shariff-Marco S, Cheng I, Jain J, Balakrishnan A, Liu L, Gupta A, Chandramouli R, Hsing A, Leung A, Singh B, Nair VS. An Analysis of Lung Cancer Screening Beliefs and Practice Patterns for Community Providers Compared to Academic Providers. Cancer Control 2018; 25:1073274818806900. [PMID: 30375235 PMCID: PMC6210633 DOI: 10.1177/1073274818806900] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/19/2018] [Accepted: 08/30/2018] [Indexed: 11/16/2022] Open
Abstract
Despite guidelines recommending annual low-dose computed tomography (LDCT) screening for lung cancer, uptake remains low due to the perceived complexity of initiating and maintaining a clinical program-problems that likely magnify in underserved populations. We conducted a survey of community providers at Federally Qualified Health Centers (FQHCs) in Santa Clara County, California, to evaluate provider-related factors that affect adherence. We then compared these findings to academic providers' (APs) LDCT screening knowledge, behaviors, and attitudes at an academic referral center in the same county. The 4 FQHCs enrolled care for 80 000 patients largely of minority descent and insured by Medi-Cal. Of the 75 FQHC providers (FQHCPs), 36 (48%) completed the survey. Of the 36 providers, 8 (22%) knew screening criteria. Fifteen (42%) FQHCPs discussed LDCT screening with patients. Compared to 36 APs, FQHCPs were more concerned about harms, false positives, discussion time, patient apathy, insurance coverage, and a lack of expertise for screening and follow-up. Yet, more FQHCPs thought screening was effective (27 [75%] of 36) compared to APs ( P = .0003). In conclusion, provider knowledge gaps are greater and barriers are different for community clinics caring for underserved populations compared to their academic counterparts, but practical and scalable solutions exist to enhance adoption.
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Affiliation(s)
- Marjon Khairy
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
- * Marjon Khairy and Duy K. Duong are equal contributors and co-primary authors
| | - Duy K. Duong
- Division of Pulmonary & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
- * Marjon Khairy and Duy K. Duong are equal contributors and co-primary authors
| | | | - Iona Cheng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Jennifer Jain
- Cancer Prevention Institute of California, Fremont, CA, USA
| | | | - Lynn Liu
- North East Medical Center, San Jose, CA, USA
| | - Aarti Gupta
- Mayview Community Health Center, Mountain View, CA, USA
| | | | - Ann Hsing
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Ann Leung
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Baldeep Singh
- Department of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, USA
| | - Viswam S. Nair
- Division of Pulmonary & Critical Care Medicine, USF Health Morsani College of Medicine, Tampa, FL, USA
- Thoracic Oncology Program, H. Lee Moffitt Cancer Center & Research Institute, University of South Florida, Tampa, FL, USA
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Readiness for Implementation of Lung Cancer Screening. A National Survey of Veterans Affairs Pulmonologists. Ann Am Thorac Soc 2017; 13:1794-1801. [PMID: 27409524 DOI: 10.1513/annalsats.201604-294oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE To mitigate the potential harms of screening, professional societies recommend that lung cancer screening be conducted in multidisciplinary programs with the capacity to provide comprehensive care, from screening through pulmonary nodule evaluation to treatment of screen-detected cancers. The degree to which this standard can be met at the national level is unknown. OBJECTIVES To assess the readiness of clinical facilities in a national healthcare system for implementation of comprehensive lung cancer screening programs, as compared with the ideal described in policy recommendations. METHODS This was a cross-sectional, self-administered survey of staff pulmonologists in pulmonary outpatient clinics in Veterans Health Administration facilities. MEASUREMENTS AND MAIN RESULTS The facility-level response rate was 84.1% (106 of 126 facilities with pulmonary clinics); 88.7% of facilities showed favorable provider perceptions of the evidence for lung cancer screening, and 73.6% of facilities had a favorable provider-perceived local context for screening implementation. All elements of the policy-recommended infrastructure for comprehensive screening programs were present in 36 of 106 facilities (34.0%); the most common deficiencies were the lack of on-site positron emission tomography scanners or radiation oncology services. Overall, 26.5% of Veterans Health Administration facilities were ideally prepared for lung cancer screening implementation (44.1% if the policy recommendations for on-site positron emission tomography scanners and radiation oncology services were waived). CONCLUSIONS Many facilities may be less than ideally positioned for the implementation of comprehensive lung cancer screening programs. To ensure safe, effective screening, hospitals may need to invest resources or coordinate care with facilities that can offer comprehensive care for screening through downstream evaluation and treatment of screen-detected cancers.
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Evaluations of Implementation at Early-Adopting Lung Cancer Screening Programs: Lessons Learned. Chest 2017; 152:70-80. [PMID: 28223153 DOI: 10.1016/j.chest.2017.02.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/24/2016] [Accepted: 02/01/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Guidelines recommend lung cancer screening (LCS), and it is currently being adopted nationwide. The American College of Chest Physicians advises inclusion of specific programmatic components to ensure high-quality screening. However, little is known about how LCS has been implemented in practice. We sought to evaluate the experience of early-adopting programs, characterize barriers faced, and identify strategies to achieve successful implementation. METHODS We performed qualitative evaluations of LCS implementation at three Veterans Administration facilities, conducting semistructured interviews with key staff (n = 29). Guided by the Promoting Action on Research Implementation in Health Services framework, we analyzed transcripts using principals of grounded theory. RESULTS Programs successfully incorporated most recommended elements of LCS, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of pulmonary nodules detected by screening and difficulty obtaining primary care "buy-in." To manage workload, programs used nurse coordinators to actively maintain screening registries, held multidisciplinary conferences that generated explicit management recommendations, and rolled out implementation in a staged fashion. Successful strategies to engage primary care providers included educational sessions, audit and feedback of local outcomes, and assisting with and assigning clear responsibility for nodule evaluation. Capitalizing on pre-existing relationships and including a designated program champion helped facilitate intradisciplinary communication. CONCLUSIONS Lung cancer screening implementation is a complex undertaking requiring coordination at many levels. The insight gained from evaluation of these early-adopting programs may inform subsequent design and implementation of LCS programs.
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Ruano-Ravina A, Provencio-Pulla M, Casan Clarà P. Cribado de cáncer de pulmón con tomografía computarizada de baja dosis. Reflexiones sobre su aplicación en España. Med Clin (Barc) 2016; 147:366-370. [DOI: 10.1016/j.medcli.2016.03.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/16/2016] [Indexed: 01/30/2023]
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