The National Lung Screening Trial demonstrated a 20% reduction in lung cancer death with annual low-radiation dose computed tomography (LDCT) screening among individuals at high risk of developing lung cancer. Multiple guidelines now recommend LDCT screening, and the VA is planning large-scale implementation of LDCT screening in 2016. While LDCT screening has the exciting potential to reduce lung cancer death, it also has the potential for high costs to the VHA and adverse outcomes for Veterans if not implemented in a careful fashion.
According to the Promoting Action on Research Implementation in Health Services (PARIHS) model, successful implementation is a function of evidence, context, and facilitation. We sought to assess VA staff and patient perceptions of the evidence, context, and facilitators to implementation of LDCT screening in VA. Our specific aims/objectives were to: 1) Conduct a diagnostic evaluation across VA facilities, to help our operational partners identify potential sites well-suited for implementation of comprehensive LDCT screening programs; 2) Perform in-depth formative evaluations of LDCT screening programs at 3 early-adopting sites, to learn how implementation has been achieved and how closely programs match the ideal specified in guidelines.
AIM 1: We administered a national online survey of VA pulmonologists that included clinical vignettes and items adapted from the 2005 VA oncology facility survey and the Organizational Readiness to Change Assessment (ORCA) instrument. We determined how closely pulmonologists' propensity to offer screening matched guideline recommendations and the factors influencing decision-making, commonly perceived barriers to implementation, and the readiness of sites to implement comprehensive LDCT screening programs.
AIM 2: We conducted formative evaluations of 3 early-adopting LDCT screening programs (Boston, West Haven, Charleston). Through qualitative interviews with 29 VA staff integral to the operation of the LDCT screening programs and 37 patients who had undergone LDCT screening within the prior year, we evaluated how evidence, context, and facilitation contributed to implementation. We analyzed transcripts following principles of grounded theory, with attention to constructs from the PARIHS framework.
AIM 1: 286 of 573 eligible pulmonologists responded, representing 106 of 125 eligible VA sites (50% individual-level response rate; 83% site-level response rate). Most respondents (78%) considered the evidence for LDCT screening to be strong or very strong. Approximately half (52%) responded to vignettes in concordance with guidelines for screening eligibility, 23% showed a propensity for over-screening, and 25% for under-screening. Factors weighted significantly more heavily by those with a propensity to screen included clinical trial evidence, guideline recommendations, and the reduction in mortality with LDCT screening. Meanwhile, those with a propensity for under-screening were significantly more influenced by concerns about the downsides of screening, including the high false positive rate, radiation exposure, detection of extrapulmonary incidentalomas, and concerns about cost-effectiveness. Commonly perceived barriers to implementation included high costs (40%), insufficient infrastructure (53%), and insufficient staff (63%). By contrast, few cited lack of support by Veterans (2%), VA clinicians (5-14%), or VA leadership (13%) as major barriers. Based on site-level analyses, 31 VA sites demonstrated readiness for implementation, with high buy-in to the evidence for LDCT screening, receptive context (based on scores on the ORCA context domain), and the necessary infrastructure to run a comprehensive multidisciplinary LDCT screening program.
AIM 2: All programs began with a core group of clinicians, often arising from an existing multidisciplinary lung cancer tumor board, who endorsed the evidence on LDCT screening, albeit with questions about effectiveness and trade-offs specifically among Veterans. All programs struggled to gain buy-in among primary care providers (PCPs), who expressed concerns about competing demands on their time, intrusive clinical reminders, insufficient knowledge about the nuances of LDCT screening to counsel patients, and anticipated high volume of screen-detected pulmonary nodules that would require evaluation. Programs gained PCP buy-in through educational sessions, program champions acting as facilitators, feedback of quality data, and making LDCT screening optional rather than a performance measure. Programs offered services to address PCP concerns (e.g., screening nurse coordinators offered shared decision-making counseling pre-screening and explicit instruction on nodule evaluation post-screening), but this resulted in high workload that quickly overwhelmed coordinators. To avoid missed or delayed cancer diagnoses, all programs emphasized the critical importance of having a coordinator and appropriate infrastructure in place to track patients through the screening and nodule evaluation process. From the patient perspective, impressions of communication surrounding LDCT screening were varied. Many patients did not feel involved in the decision to undergo LDCT screening. Indeed, several patients reported that they were simply told by their clinicians that they needed a CT scan to check on their lungs, without further discussion of the rationale, benefits, or harms of screening. When discussions to screen were handled by the screening nurse coordinator using a decision aid, patients were more likely to remember a more thorough discussion of the trade-offs of screening than when the PCP or pulmonologist conducted the discussion; while some patients appreciated this discussion of trade-offs, others reported that the discussion of potential harms caused anxiety. With regard to receiving results of the screening CT scans, many patients felt the information provided was inadequate and were left with unanswered questions. Patients with larger nodules tended to receive more prompt and more complete information and were typically more satisfied with the process. Almost all patients would recommend LDCT screening to other Veterans at increased risk of developing lung cancer.
Effective implementation of LDCT programs will allow VA to maximize benefits of screening while minimizing potential harms. We have identified sites with high readiness to implementation, delineated successful strategies for implementation, and identified gaps in communication and decision-making that must be remedied to provide patient-centered care to Veterans undergoing LDCT screening. This project has provided invaluable information to our clinical and operational partners, the National Program Offices for Oncology and Pulmonology, and the National Center for Health Promotion and Disease Prevention, as they prepare to roll-out lung cancer screening in the VHA in 2016.
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