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Tiase VL, Richards G, Taft T, Stevens L, Balbin C, Kaphingst KA, Fagerlin A, Caverly T, Kukhareva P, Flynn M, Butler JM, Kawamoto K. Patient Perspectives on a Patient-Facing Tool for Lung Cancer Screening. Health Expect 2024; 27:e14143. [PMID: 38992907 PMCID: PMC11239535 DOI: 10.1111/hex.14143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/02/2024] [Accepted: 06/27/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Individuals with high risk for lung cancer may benefit from lung cancer screening, but there are associated risks as well as benefits. Shared decision-making (SDM) tools with personalized information may provide key support for patients. Understanding patient perspectives on educational tools to facilitate SDM for lung cancer screening may support tool development. AIM This study aimed to explore patient perspectives related to a SDM tool for lung cancer screening using a qualitative approach. METHODS We elicited patient perspectives by showing a provider-facing SDM tool. Focus group interviews that ranged in duration from 1.5 to 2 h were conducted with 23 individuals with high risk for lung cancer. Data were interpreted inductively using thematic analysis to identify patients' thoughts on and desires for a patient-facing SDM tool. RESULTS The findings highlight that patients would like to have educational information related to lung cancer screening. We identified several key themes to be considered in the future development of patient-facing tools: barriers to acceptance, preference against screening and seeking empowerment. One further theme illustrated effects of patient-provider relationship as a limitation to meeting lung cancer screening information needs. Participants also noted several suggestions for the design of technology decision aids. CONCLUSION These findings suggest that patients desire additional information on lung cancer screening in advance of clinical visits. However, there are several issues that must be considered in the design and development of technology to meet the information needs of patients for lung cancer screening decisions. PATIENT OR PUBLIC CONTRIBUTION Patients, service users, caregivers or members of the public were not involved in the study design, conduct, analysis or interpretation of the data. However, clinical experts in health communication provided detailed feedback on the study protocol, including the focus group approach. The study findings contribute to a better understanding of patient expectations for lung cancer screening decisions and may inform future development of tools for SDM.
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Affiliation(s)
- Victoria L Tiase
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Grace Richards
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - Teresa Taft
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Leticia Stevens
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Christian Balbin
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Kimberly A Kaphingst
- Department of Communication and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Tanner Caverly
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Polina Kukhareva
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Michael Flynn
- Departments of Internal Medicine and Pediatrics, Community Physicians Group, University of Utah Health, Salt Lake City, Utah, USA
| | - Jorie M Butler
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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Carter-Bawa L, Slaven JE, Monahan PO, Brandzel S, Gao H, Wernli KJ, Lafata JE, Rawl SM. Unpacking the relationship between shared decision-making and decisional quality, decision to screen, and screening completion in lung cancer screening. PATIENT EDUCATION AND COUNSELING 2024; 122:108143. [PMID: 38237528 PMCID: PMC10922311 DOI: 10.1016/j.pec.2024.108143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/09/2023] [Accepted: 01/08/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES Lung cancer screening is a complex and individualized decision. To understand how best to support patients in this decision, we must understand how shared decision-making is associated with both decisional and behavioral outcomes. METHODS Observational cohort study combining patient survey data with electronic health record data of lung screening-eligible patients who recently engaged in a shared decision-making discussion about screening with a primary care clinician. RESULTS Using multivariable analysis (n = 529), factors associated with higher lung cancer screening decisional quality include higher knowledge (OR = 1.33, p < .0001), lower perceived benefits (OR = 0.90, p = .0004), higher perceived barriers (OR = 1.07, p < .0001), higher self-efficacy (OR = 1.13, p < .0001), and higher levels of perceiving the discussion was shared (OR = 1.04, p < .0001). Factors associated with the patient's decision to screen include older age (OR = 1.12, p = .0050) and higher self-efficacy (OR = 1.11, p = .0407). Factors associated with screening completion included older age (OR = 1.05, p = .0050), higher knowledge (OR = 1.24, p = .0045), and higher self-efficacy (OR = 1.12, p = .0003). CONCLUSIONS Shared decision-making in lung cancer screening is a dyadic process between patient and clinician. As we continue to strive for high-quality patient-centered care, patient decision quality may be enhanced by targeting key factors such as high-quality knowledge, self-efficacy, and fostering a shared discussion to support patient engagement in lung cancer screening decisions.
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Affiliation(s)
- Lisa Carter-Bawa
- Center for Discovery & Innovation at Hackensack Meridian Health, Nutley, NJ, USA; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA.
| | - James E Slaven
- Indiana University School of Medicine, Department of Biostatistics and Health Data Science, Indianapolis, IN, USA
| | - Patrick O Monahan
- Indiana University School of Medicine, Department of Biostatistics and Health Data Science, Indianapolis, IN, USA
| | - Susan Brandzel
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jennifer Elston Lafata
- UNC Eshelman School of Pharmacy and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, NC, USA
| | - Susan M Rawl
- Indiana University School of Nursing, Indianapolis, IN, USA; Indiana University Melvin & Bren Simon Comprehensive Cancer Center, Indianapolis, IN, USA
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3
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Pettit NR, Horner D, Freeman S, Rieger K. Pilot intervention to increase uptake of lung cancer screening through the emergency department. Am J Emerg Med 2024; 79:157-160. [PMID: 38432156 DOI: 10.1016/j.ajem.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION The goal of this study is to demonstrate the feasibility of referring patients for lung cancer screening (LCS) from the emergency department (ED) as a method to increase the uptake of LCS. METHODS This is a single-arm pilot study at a large safety-net ED. ED LCS-eligible patients were offered a referral to our LCS clinic upon ED discharge. The primary outcome was the frequency at which patients connected with the LCS clinic. RESULTS During the study period, 105 patients were approached; 26 (24.8%) participated. Reasons for non-enrollment include 29 (27.6%) who were not interested in research, 10 (9.5%) who did not speak English, and 40 (38.1%) who did not meet the pack-years criteria. Seventeen patients (65.4%, 17/26) connected with the LCS clinic, with 10 (38.5%) having been seen in the clinic and received a low dose computed tomography (LDCT) scan. Of the 17 that were connected with the clinic, 7 (26.9%) had a non-LDCT chest CT scan in the past year. Of those that were not seen in the clinic (n = 9), 4 (44.4%) were unreachable via 3 phone calls and a post-marked letter, and 3 (33.3%) did not attend the scheduled appointment, and 2 (22.2%) were delayed due to COVID-19. Of those that had CT scans over the study period (n = 17), 0 scans were normal, one patient (5.9%) had asymptomatic lung cancer, 7 (41.2%) had pulmonary nodules, 11 (64.7%) had emphysema, and 9 (52.9%) had coronary artery disease. CONCLUSION This pilot study suggests the feasibility and suggests initial indications of the efficacy of referring ED patients for LCS.
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Affiliation(s)
- Nicholas R Pettit
- Department of Emergency Medicine, Indiana University, Indianapolis, IN, United States of America.
| | - Diane Horner
- Eskenazi Health, Lung Cancer Screening Program, Indianapolis, IN, United States of America
| | - Sara Freeman
- Eskenazi Health, Lung Cancer Screening Program, Indianapolis, IN, United States of America
| | - Karen Rieger
- Eskenazi Health, Lung Cancer Screening Program, Indianapolis, IN, United States of America; Department of Thoracic Surgery, Indiana University, Indianapolis, IN, United States of America
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Odole IP, Andersen M, Richman IB. Digital Interventions to Support Lung Cancer Screening: A Systematic Review. Am J Prev Med 2024; 66:899-908. [PMID: 38246408 DOI: 10.1016/j.amepre.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION Lung cancer remains a leading cause of cancer-related deaths globally. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce lung cancer mortality, but its adoption in the U.S. has been limited. Digital interventions have the potential to improve uptake of LCS. This systematic review aims to summarize the evidence for the effectiveness of digital interventions in promoting LCS. METHODS A systematic search of three electronic databases (PubMed, Embase, and Medline) was conducted to identify studies published between January 2014 and May 2023. Studies were reviewed and abstracted between February 2023 and July 2023. Outcomes related to knowledge, decision-making and screening were measured. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools. RESULTS Of 1,979 screened articles, 30 studies were included in this review. Digital interventions evaluated included decision aids (n=20), electronic health record (EHR)-based interventions (n=7), social media campaigns and mobile applications (n=3). Decision aids were the most commonly studied digital interventions, with most studies showing improved knowledge (13/13) and reduced decisional conflict (7/9) but most did not show a substantial change in screening use. Fewer studies tested clinician-facing or multi-level interventions. DISCUSSION Digital interventions, particularly decision aids, have shown promise in improving knowledge and the quality of decision-making around LCS. However, few interventions have been shown to substantially alter screening behavior and few clinician-facing or multi-level interventions have been rigorously tested. Further research is needed to develop effective tools for engaging patients in LCS, to compare the efficacy of different interventions, and evaluate implementation strategies in diverse healthcare settings.
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Affiliation(s)
| | | | - Ilana B Richman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
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5
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Lin X, Lei F, Lin J, Li Y, Chen Q, Arbing R, Chen WT, Huang F. Promoting Lung Cancer Screen Decision-Making and Early Detection Behaviors: A Systematic Review and Meta-analysis. Cancer Nurs 2024:00002820-990000000-00227. [PMID: 38498799 DOI: 10.1097/ncc.0000000000001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Promoting lung cancer screening (LCS) is complex. Previous studies have overlooked that LCS behaviors are stage based and thus did not identify the characteristics of LCS interventions at different screening stages. OBJECTIVE The aims of this study were to explore the characteristics and efficacy of interventions in promoting LCS decision making and behaviors and to evaluate these interventions. METHODS We conducted a study search from the inception of each bibliographic database to April 8, 2023. The precaution adoption process model was used to synthesize and classify the evidence. The RE-AIM framework was used to evaluate the effectiveness of LCS programs. Heterogeneity tests and meta-analysis were performed using RevMan 5.4 software. RESULTS We included 31 studies that covered 4 LCS topics: knowledge of lung cancer, knowledge of LCS, value clarification exercises, and LCS supportive resources. Patient decision aids outperformed educational materials in improving knowledge and decision outcomes with a significant reduction in decision conflict (standardized mean difference, 0.81; 95% confidence interval, -1.15 to -0.47; P < .001). Completion rates of LCS ranged from 3.6% to 98.8%. Interventions that included screening resources outperformed interventions that used patient decision aids alone in improving LCS completion. The proportions of reported RE-AIM indicators were highest for reach (69.59%), followed by adoption (43.87%), effectiveness (36.13%), implementation (33.33%), and maintenance (9.68%). CONCLUSION Evidence from 31 studies identified intervention characteristics and effectiveness of LCS interventions based on different stages of decision making. IMPLICATIONS FOR PRACTICE It is crucial to develop targeted and systematic interventions based on the characteristics of each stage of LCS to maximize intervention effectiveness and reduce the burden of lung cancer.
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Affiliation(s)
- Xiujing Lin
- Author Affiliations: School of Nursing, Fujian Medical University (Mss X Lin, J Lin, Li, and Q Chen, and Dr Huang), Fuzhou, China; School of Nursing, University of Minnesota (Dr Lei), Twin Cities, Minneapolis; and School of Nursing, University of California Los Angeles (Dr W-T Chen and Ms Arbing)
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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Carter-Bawa L, Ostroff JS, Hoover K, Studts JL. Effective Communication About Lung Cancer Screening Without Iatrogenic Stigma: A Brief Report Case Study Using the Lung Cancer Stigma Communications Assessment Tool of LungTalk. JTO Clin Res Rep 2023; 4:100585. [PMID: 38029025 PMCID: PMC10679887 DOI: 10.1016/j.jtocrr.2023.100585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Stigma thwarts progress in lung cancer risk reduction and control and adversely affects patients across the entire lung cancer care continuum. In developing and disseminating patient and public-facing interventions to increase lung screening, we must be cognizant of how communications have the potential for further stigmatization of at-risk populations. Creation of the Lung Cancer Stigma Communications Assessment Tool (LCS-CAT) version 1 was supported by the American Cancer Society's National Lung Cancer Roundtable to help content developers identify, remove, and replace potentially stigmatizing language and imagery from materials designed to engage individuals across the lung cancer continuum. Methods The LCS-CAT considers language, imagery, and context and was used to audit a public-facing health communication and decision support tool called LungTalk. Results The audit performed by two behavioral scientists revealed multiple issues in all three areas, and specific feedback and alternatives were identified. Conclusions Applying the LCS-CAT to LungTalk was a productive process that helped remove potentially stigmatizing language and imagery from this tool designed to engage individuals in the process of making an informed decision about lung screening. To support destigmatization of lung cancer, communication creators should consider a stigma biopsy on all public-facing campaigns for lung screening to help identify, eliminate, and replace messages that could compromise engagement with the lung cancer screening opportunity.
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Affiliation(s)
- Lisa Carter-Bawa
- Center for Discovery & Innovation at Hackensack Meridian Health, Cancer Prevention Precision Control Institute, Nutley, New Jersey
| | - Jamie S. Ostroff
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kaitlyn Hoover
- Cancer Prevention and Control, University of Colorado Cancer Center, Aurora, Colorado
| | - Jamie L. Studts
- Cancer Prevention and Control, University of Colorado Cancer Center, Aurora, Colorado
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Schapira MM, Hubbard RA, Whittle J, Vachani A, Kaminstein D, Chhatre S, Rodriguez KL, Bastian LA, Kravetz JD, Asan O, Prigge JM, Meline J, Schrand S, Ibarra JV, Dye DA, Rieder JB, Frempong JO, Fraenkel L. Lung Cancer Screening Decision Aid Designed for a Primary Care Setting: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2330452. [PMID: 37647070 PMCID: PMC10469267 DOI: 10.1001/jamanetworkopen.2023.30452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/09/2023] [Indexed: 09/01/2023] Open
Abstract
Importance Guidelines recommend shared decision-making prior to initiating lung cancer screening (LCS). However, evidence is lacking on how to best implement shared decision-making in clinical practice. Objective To evaluate the impact of an LCS Decision Tool (LCSDecTool) on the quality of decision-making and LCS uptake. Design, Setting, and Participants This randomized clinical trial enrolled participants at Veteran Affairs Medical Centers in Philadelphia, Pennsylvania; Milwaukee, Wisconsin; and West Haven, Connecticut, from March 18, 2019, to September 29, 2021, with follow-up through July 18, 2022. Individuals aged 55 to 80 years with a smoking history of at least 30 pack-years who were current smokers or had quit within the past 15 years were eligible to participate. Individuals with LCS within 15 months were excluded. Of 1047 individuals who were sent a recruitment letter or had referred themselves, 140 were enrolled. Intervention A web-based patient- and clinician-facing LCS decision support tool vs an attention control intervention. Main Outcome and Measures The primary outcome was decisional conflict at 1 month. Secondary outcomes included decisional conflict immediately after intervention and 3 months after intervention, knowledge, decisional regret, and anxiety immediately after intervention and 1 and 3 months after intervention and LCS by 6 months. Results Of 140 enrolled participants (median age, 64.0 [IQR, 61.0-69.0] years), 129 (92.1%) were men and 11 (7.9%) were women. Of 137 participants with data available, 75 (53.6%) were African American or Black and 62 (44.3%) were White; 4 participants (2.9%) also reported Hispanic or Latino ethnicity. Mean decisional conflict score at 1 month did not differ between the LCSDecTool and control groups (25.7 [95% CI, 21.4-30.1] vs 29.9 [95% CI, 25.6-34.2], respectively; P = .18). Mean LCS knowledge score was greater in the LCSDecTool group immediately after intervention (7.0 [95% CI, 6.3-7.7] vs 4.9 [95% CI, 4.3-5.5]; P < .001) and remained higher at 1 month (6.3 [95% CI, 5.7-6.8] vs 5.2 [95% CI, 4.5-5.8]; P = .03) and 3 months (6.2 [95% CI, 5.6-6.8] vs 5.1 [95% CI, 4.4-5.8]; P = .01). Uptake of LCS was greater in the LCSDecTool group at 6 months (26 of 69 [37.7%] vs 15 of 71 [21.1%]; P = .04). Conclusions and Relevance In this randomized clinical trial of an LCSDecTool compared with attention control, no effect on decisional conflict occurred at 1 month. The LCSDecTool used in the primary care setting did not yield a significant difference in decisional conflict. The intervention led to greater knowledge and LCS uptake. These findings can inform future implementation strategies and research in LCS shared decision-making. Trial Registration ClinicalTrials.gov Identifier: NCT02899754.
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Affiliation(s)
- Marilyn M Schapira
- Center for Health Equity Research and Promotion (CHERP), Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia
| | - Jeff Whittle
- Division of Medicine, Clement J Zablocki VA Medical Center, Milwaukee, Wisconsin
- Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa
| | - Anil Vachani
- Department of Medicine, Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Dana Kaminstein
- Center for Health Equity Research and Promotion (CHERP), Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
- Department of Organizational Dynamics, School of Arts & Sciences, University of Pennsylvania, Philadelphia
| | - Sumedha Chhatre
- Center for Health Equity Research and Promotion (CHERP), Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Keri L Rodriguez
- CHERP, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Lori A Bastian
- Department of Medicine, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven
| | - Jeffrey D Kravetz
- Department of Medicine, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven
| | - Onur Asan
- The Stevens Institute of Technology, School of Systems and Enterprise, Hoboken, New Jersey
| | - Jason M Prigge
- Center for Health Equity Research and Promotion (CHERP), Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
| | - Jessica Meline
- Center for Health Equity Research and Promotion (CHERP), Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
| | - Susan Schrand
- Department of Medicine, Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | - Deborah A Dye
- Office of Research, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
| | - Julie B Rieder
- Office of Research, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
| | - Jemimah O Frempong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Liana Fraenkel
- Department of Medicine, Yale University, New Haven, Connecticut
- Berkshire Health Systems, Pittsfield, Massachusetts
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Gomes R, Nederveld A, Glasgow RE, Studts JL, Holtrop JS. Lung cancer screening in rural primary care practices in Colorado: time for a more team-based approach? BMC PRIMARY CARE 2023; 24:62. [PMID: 36869308 PMCID: PMC9982804 DOI: 10.1186/s12875-023-02003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Despite lung cancer being a leading cause of death in the United States and lung cancer screening (LCS) being a recommended service, many patients eligible for screening do not receive it. Research is needed to understand the challenges with implementing LCS in different settings. This study investigated multiple practice members and patient perspectives impacting rural primary care practices related to LCS uptake by eligible patients. METHODS This qualitative study involved primary care practice members in multiple roles (clinicians n = 9, clinical staff n = 12 and administrators n = 5) and their patients (n = 19) from 9 practices including federally qualified and rural health centers (n = 3), health system owned (n = 4) and private practices (n = 2). Interviews were conducted regarding the importance of and ability to complete the steps that may result in a patient receiving LCS. Data were analyzed using a thematic analysis with immersion crystallization then organized using the RE-AIM implementation science framework to illuminate and organize implementation issues. RESULTS Although all groups endorsed the importance of LCS, all also struggled with implementation challenges. Since assessing smoking history is part of the process to identify eligibility for LCS, we asked about these processes. We found that smoking assessment and assistance (including referral to services) were routine in the practices, but other steps in the LCS portion of determining eligibility and offering LCS were not. Lack of knowledge about screening and coverage, patient stigma, and resistance and practical considerations such as distance to LCS testing facilities complicated completion of LCS compared to screening for other types of cancer. CONCLUSIONS Limited uptake of LCS results from a range of multiple interacting factors that cumulatively affect consistency and quality of implementation at the practice level. Future research should consider team-based approaches to conduct of LCS eligibility and shared decision making.
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Affiliation(s)
- Rebekah Gomes
- University of Colorado Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), Aurora, CO, USA
| | - Andrea Nederveld
- Department of Family Medicine, University of Colorado School of Medicine, Mail Stop F496, 12631 E. 17Th Ave, Aurora, CO, 80045, USA
| | - Russell E Glasgow
- University of Colorado Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), Aurora, CO, USA.,Department of Family Medicine, University of Colorado School of Medicine, Mail Stop F496, 12631 E. 17Th Ave, Aurora, CO, 80045, USA
| | - Jamie L Studts
- Department of Medicine, Division of Medical Oncology, and University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jodi Summers Holtrop
- University of Colorado Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), Aurora, CO, USA. .,Department of Family Medicine, University of Colorado School of Medicine, Mail Stop F496, 12631 E. 17Th Ave, Aurora, CO, 80045, USA.
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Preliminary Testing of A Web-Based Lung Cancer Screening Decision Coaching Toolfor Older Chinese American Smokers and Their Providers. J Natl Med Assoc 2023; 115:223-232. [PMID: 36803851 DOI: 10.1016/j.jnma.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/16/2023] [Accepted: 01/25/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVES To examine the acceptability of a culturally targeted lung cancer screening decision aid developed for older Chinese Americans with a smoking history and primary care providers serving this patient population. METHODS Study participants reviewed a web-based decision aid (DA) for lung cancer screening named "Lung Decisions Coaching Tool (LDC-T)." Participants completed a baseline survey and were invited to join an interview. During the interview, participants engaged with the Lung Decisions Coaching Tool and then completed standardized measures of acceptability, usability, and satisfaction. RESULTS Chinese American smokers (N =22) and Chinese American physicians (N=10) rated the acceptability and usability of a patient version and provider versions of the LDC-T, respectively. Patient version demonstrated high levels of acceptability, usability and satisfaction. Most participants rated the information provided as good or excellent, the amount of tool information was just right, and they thought the tool would be useful for making a screening decision. The tool was well received by participants for ease of use and well-integrated functions. Furthermore, participants indicated they would like to use the tool to help prepare for lung cancer screening shared decision-making with their provider. Similar results were found for the provider version of the LDC-T. CONCLUSIONS Lung cancer screening represents an evidence-based approach to reducing lung cancer morbidity and mortality among chronic high-frequency smokers. Study results suggest the acceptability of a culturally targeted lung cancer screening decision aid for Chinese American smokers and providers. Additional research is needed to determine the effectiveness of the DA in increasing appropriate levels of screening in this underserved population.
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Carter-Bawa L, Walsh LE, Schofield E, Williamson TJ, Hamann HA, Ostroff JS. Lung Cancer Screening Knowledge, Attitudes, and Practice Patterns Among Primary and Pulmonary Care Clinicians. Nurs Res 2023; 72:3-11. [PMID: 36260526 PMCID: PMC9772114 DOI: 10.1097/nnr.0000000000000629] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Lung cancer screening has the potential to identify lung cancer at an early stage when more treatment options exist. However, discussions with and referrals of screening-eligible patients remain unacceptably low. We need to better understand clinician knowledge, attitudes, and practice patterns to identify strategies to improve lung cancer screening uptake. Prior studies have focused on understanding these factors from physicians only. Nevertheless, many patients receive primary care from nurse practitioners and physician assistants where prevention and early detection conversations are most likely to occur. Therefore, we must engage the full range of clinicians treating screening-eligible patients. OBJECTIVES The aim of this study was to describe attitudes, beliefs and referral practice patterns, lung cancer screening knowledge, and concordance with lung cancer screening guidelines among nurse practitioners, physicians, and physician assistants in the United States. METHODS A descriptive, cross-sectional study was performed using survey methodology with clinical vignettes to examine clinician factors and concordance with U.S. Preventive Services Task Force lung cancer screening guidelines. RESULTS Participants scored low on attitudes toward shared decision-making, high on the importance of shared decision-making in lung cancer screening, and low on barriers to lung cancer screening referral. In addition, midrange scores on empathy toward patients with smoking history were noted. Lung cancer screening knowledge was low regardless of clinician specialty; the most endorsed response when presented with a hypothetical patient was to refer for lung cancer screening using a chest X-ray. DISCUSSION Findings demonstrate that most clinicians are nonconcordant with U.S. Preventive Services Task Force guidelines, erroneously believing a chest X-ray is appropriate for lung cancer screening. Clinicians must follow evidence-based practice guidelines, highlighting the need for targeted continuing education about lung cancer screening for clinicians who treat screening-eligible patients.
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12
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Carter-Bawa L, Schofield E, Atkinson TM, Ostroff JS. Development and psychometric evaluation of the Spanish version of the lung cancer screening health belief scale. Eur J Cancer Care (Engl) 2022; 31:e13707. [PMID: 36109851 PMCID: PMC10074415 DOI: 10.1111/ecc.13707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to describe the translation and psychometric testing of the Lung Cancer Screening Health Belief Scale (LCSHBS) into Spanish. METHODS The English version of the LCSHBS was professionally translated in accordance with best practices in the translation of patient-reported outcome tools. The independent certified professional translator completed a forward translation of the LCSHBS from English to Spanish, followed by a review of the translated questionnaire by a certified Memorial Sloan Kettering Cancer Center Spanish-English bicultural expert, who reviewed the scale for accuracy. RESULTS Initial testing of the scales is valid and reliable, and supports the Spanish version of the LCSHBS (LCSHBS-S). Internal consistency reliability of the scales was supported with Cronbach's ranging from 0.81 to 0.96. Construct validity was established with confirmatory factor analysis and testing for differences between individuals who have and have not screened in theoretically proposed directions. These newly translated scales can help investigators expand this research into the large Spanish-speaking lung screening-eligible population as they develop and test critical behavioural interventions to increase lung cancer screening in the at-risk population. CONCLUSIONS Development of effective interventions to enhance shared decision-making about lung cancer screening between patients and providers must first identify factors influencing the individual's screening participation. Future efforts facilitating patient-provider conversations are better informed by understanding the perspective of the individual making the decision.
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Affiliation(s)
- Lisa Carter-Bawa
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth Schofield
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Thomas M Atkinson
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jamie S Ostroff
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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13
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Hamdiui N, Stein ML, van Steenbergen J, Crutzen R, Bouman M, Khan A, Çetin MN, Timen A, van den Muijsenbergh M. Evaluation of a Web-Based Culturally Sensitive Educational Video to Facilitate Informed Cervical Cancer Screening Decisions Among Turkish- and Moroccan-Dutch Women Aged 30 to 60 Years: Randomized Intervention Study. J Med Internet Res 2022; 24:e35962. [DOI: 10.2196/35962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background
In the Netherlands, since 1996, a national cervical cancer (CC) screening program has been implemented for women aged 30 to 60 years. Regional screening organizations send an invitation letter and information brochure in Dutch to the home addresses of targeted women every 5 years. Although this screening is free of charge, Turkish- and Moroccan-Dutch women, especially, show low screening participation and limited informed decision-making (IDM). As Turkish- and Moroccan-Dutch women indicated their need for information on the practical, emotional, cultural, and religious aspects of CC screening, we developed a culturally sensitive educational video (CSEV) as an addition to the current information brochure.
Objective
In this study, we aimed to evaluate the added effect of the CSEV on IDM regarding CC screening participation among Turkish and Moroccan women aged 30 to 60 years in the Netherlands through a randomized intervention study.
Methods
Initial respondents were recruited via several social media platforms and invited to complete a web-based questionnaire. Following respondent-driven sampling, respondents were asked to recruit a number of peers from their social networks to complete the same questionnaire. Respondents were randomly assigned to the control (current information brochure) or intervention condition (brochure and CSEV). We measured respondents’ knowledge and attitude regarding CC screening and their intention to participate in the next CC screening round before and after the control or intervention condition. We evaluated the added effect of the CSEV (above the brochure) on their knowledge, attitude, intention, and IDM using intention-to-treat analyses.
Results
The final sample (n=1564) included 686 (43.86%) Turkish and 878 (56.14%) Moroccan-Dutch women. Of this sample, 50.7% (793/1564) were randomized to the control group (350/793, 44.1% Turkish and 443/793, 55.9% Moroccan) and 49.3% (771/1564) to the intervention group (336/771, 43.6% Turkish and 435/771, 56.4% Moroccan). Among the Turkish-Dutch women, 33.1% (116/350) of the control respondents and 40.5% (136/336) of the intervention respondents consulted the brochure (not statistically significant). Among Moroccan-Dutch women, these percentages were 28.2% (125/443) and 37.9% (165/435), respectively (P=.003). Of all intervention respondents, 96.1% (323/336; Turkish) and 84.4% (367/435; Moroccan) consulted the CSEV. The CSEV resulted in more positive screening attitudes among Moroccan-Dutch women than the brochure (323/435, 74.3% vs 303/443, 68.4%; P=.07). Women, who had never participated in CC screening before, showed significantly more often a positive attitude toward CC screening compared with the control group (P=.01).
Conclusions
Our short and easily implementable CSEV resulted in more positive screening attitudes, especially in Moroccan-Dutch women. As the CSEV was also watched far more often than the current brochure was read, this intervention can contribute to better reach and more informed CC screening decisions among Turkish- and Moroccan-Dutch women.
Trial Registration
International Clinical Trial Registry Platform NL8453; https://tinyurl.com/2dvbjxvc
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Lin YA, Hong YT, Lin XJ, Lin JL, Xiao HM, Huang FF. Barriers and facilitators to uptake of lung cancer screening: A mixed methods systematic review. Lung Cancer 2022; 172:9-18. [PMID: 35963208 DOI: 10.1016/j.lungcan.2022.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/02/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022]
Abstract
Numerous factors contribute to the low adherence to lung cancer screening (LCS) programs. A theory-informed approach to identifying the obstacles and facilitators to LCS uptake is required. This study aimed to identify, assess, and synthesize the available literature at the individual and healthcare provider (HCP) levels based on a social-ecological model and identify gaps to improve practice and policy decision-making. Systematic searches were conducted in nine electronic databases from inception to December 31, 2020. We also searched Google Scholar and manually examined the reference lists of systematic reviews to include relevant articles. Primary studies were scored for quality assessment. Among 3938 potentially relevant articles, 36 studies, including 25 quantitative and 11 qualitative studies, were identified for inclusion in the review. Fifteen common factors were extracted from 34 studies, including nine barriers and six facilitators. The barriers included individual factors (n = 5), health system factors (n = 3), and social/environmental factors (n = 1). The facilitators included only individual factors (n = 6). However, two factors, age and screening harm, remain mixed. This systematic review identified and combined barriers and facilitators to LCS uptake at the individual and HCP levels. The interaction mechanisms among these factors should be further explored, which will allow the construction of tailored LCS recommendations or interventions for the Chinese context.
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Affiliation(s)
- Yu-An Lin
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Yu Ting Hong
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiu Jing Lin
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Jia Ling Lin
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Hui Min Xiao
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Fei Fei Huang
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China.
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Lowenstein M, Karliner L, Livaudais-Toman J, Gregorich S, Velazquez AI, Vijayaraghavan M, Walsh JM, Kaplan CP. Barriers and Facilitators to Lung Cancer Screening: A Physician Survey. Am J Health Promot 2022; 36:1208-1212. [DOI: 10.1177/08901171221088849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose To describe barriers to lung cancer screening (LCS) among family medicine and general internal medicine primary care physicians (PCPs) and assess the association of barriers with discussion and referral for screening. Design Cross-sectional survey. Subjects and Settings Random sample of primary care physicians (PCPs) in California. Measures PCP practices for discussion and referral for LCS and ratings of LCS barriers. Analysis We performed exploratory factor analysis to identify four barrier constructs: (1) Physician Visit-Level Barriers to screening referral; (2) Physician System and Evidence Barriers; (3) Patient Cost Barrier; and (4) Other Patient Barriers. We then performed multivariable logistic regression adjusted for physician and practice characteristics to assess the association between the physician-reported barriers and whether PCPs discussed or referred for LCS. Results 368 physicians responded (response rate 42%). Most worked in large metropolitan areas (80%) and large health systems (59%). After adjusting for physician and practice characteristics, we found that physician-reporting of System and Evidence Barriers was associated with lower odds of discussion or referral for LDCT (aOR .18, 95% CI 0.09–0.37), while physician-reported Visit-Level Barriers were associated with increased odds discussion or referral (aOR 2.65, 95% CI 1.30–5.04). Conclusions While physicians reported numerous barriers to LCS, we found that barriers were differentially associated with discussion or referral for screening. As new LCS guidelines broaden screening eligibility, it is critical to address these barriers to achieve higher rates of evidence-based LCS.
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Affiliation(s)
- Margaret Lowenstein
- Department of Medicine, Division of General Internal Medicine and Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Leah Karliner
- Department of Medicine, Division of General Internal Medicine and Multi-Ethnic Health Equity Research Center, University of California (UCSF), San Francisco CA, USA
| | | | - Steven Gregorich
- Department of Medicine, Division of General Internal Medicine and MERC, San Francisco, CA, USA
| | - Ana I. Velazquez
- Department of Medicine, Division of Hematology/Oncology and National Clinician Scholars Program, UCSF, San Francisco, CA, USA
| | - Maya Vijayaraghavan
- Department of Medicine, Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Judith M.E. Walsh
- Department of Medicine, Division of General Internal Medicine, MERC, and Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, USA
| | - Celia P. Kaplan
- Department of Medicine, Division of General Internal Medicine, MERC, and Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, USA
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Lowery J, Fagerlin A, Larkin AR, Wiener RS, Skurla SE, Caverly TJ. Implementation of a Web-Based Tool for Shared Decision-making in Lung Cancer Screening: Mixed Methods Quality Improvement Evaluation. JMIR Hum Factors 2022; 9:e32399. [PMID: 35363144 PMCID: PMC9015752 DOI: 10.2196/32399] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/28/2021] [Accepted: 11/28/2021] [Indexed: 12/18/2022] Open
Abstract
Background Lung cancer risk and life expectancy vary substantially across patients eligible for low-dose computed tomography lung cancer screening (LCS), which has important consequences for optimizing LCS decisions for different patients. To account for this heterogeneity during decision-making, web-based decision support tools are needed to enable quick calculations and streamline the process of obtaining individualized information that more accurately informs patient-clinician LCS discussions. We created DecisionPrecision, a clinician-facing web-based decision support tool, to help tailor the LCS discussion to a patient’s individualized lung cancer risk and estimated net benefit. Objective The objective of our study is to test two strategies for implementing DecisionPrecision in primary care at eight Veterans Affairs medical centers: a quality improvement (QI) training approach and academic detailing (AD). Methods Phase 1 comprised a multisite, cluster randomized trial comparing the effectiveness of standard implementation (adding a link to DecisionPrecision in the electronic health record vs standard implementation plus the Learn, Engage, Act, and Process [LEAP] QI training program). The primary outcome measure was the use of DecisionPrecision at each site before versus after LEAP QI training. The second phase of the study examined the potential effectiveness of AD as an implementation strategy for DecisionPrecision at all 8 medical centers. Outcomes were assessed by comparing absolute tool use before and after AD visits and conducting semistructured interviews with a subset of primary care physicians (PCPs) following the AD visits. Results Phase 1 findings showed that sites that participated in the LEAP QI training program used DecisionPrecision significantly more often than the standard implementation sites (tool used 190.3, SD 174.8 times on average over 6 months at LEAP sites vs 3.5 SD 3.7 at standard sites; P<.001). However, this finding was confounded by the lack of screening coordinators at standard implementation sites. In phase 2, there was no difference in the 6-month tool use between before and after AD (95% CI −5.06 to 6.40; P=.82). Follow-up interviews with PCPs indicated that the AD strategy increased provider awareness and appreciation for the benefits of the tool. However, other priorities and limited time prevented PCPs from using them during routine clinical visits. Conclusions The phase 1 findings did not provide conclusive evidence of the benefit of a QI training approach for implementing a decision support tool for LCS among PCPs. In addition, phase 2 findings showed that our light-touch, single-visit AD strategy did not increase tool use. To enable tool use by PCPs, prediction-based tools must be fully automated and integrated into electronic health records, thereby helping providers personalize LCS discussions among their many competing demands. PCPs also need more time to engage in shared decision-making discussions with their patients. Trial Registration ClinicalTrials.gov NCT02765412; https://clinicaltrials.gov/ct2/show/NCT02765412
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Affiliation(s)
- Julie Lowery
- Center for Clinical Management Research, Ann Arbor VA Healthcare System, Ann Arbor, MI, United States
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States
- Informatics Decision-Enhancement and Analytics Sciences Center for Innovation, VA Salt Lake City Healthcare System, Salt Lake City, MI, United States
| | - Angela R Larkin
- Center for Clinical Management Research, Ann Arbor VA Healthcare System, Ann Arbor, MI, United States
| | - Renda S Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA, United States
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, United States
| | - Sarah E Skurla
- Center for Clinical Management Research, Ann Arbor VA Healthcare System, Ann Arbor, MI, United States
| | - Tanner J Caverly
- Center for Clinical Management Research, Ann Arbor VA Healthcare System, Ann Arbor, MI, United States
- Department of Learning Health Sciences, University of Michigan School of Medicine, Ann Arbor, MI, United States
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
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