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Abstract Background The United States Preventive Services Task Force (USPSTF) issued recommendations for older, heavy lifetime smokers to complete annual low-dose computed tomography (LDCT) scans of the chest as screening for lung cancer. The USPSTF recommends and the Centers for Medicare and Medicaid Services require shared decision making using a...
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Soon after the National Lung Screening Trial, organizations began to endorse low-dose computed tomography (LCDT) screening for lung cancer in high-risk patients. Concerns about the risks versus benefits of screening, as well as the logistics of identifying and referring eligible patients, remained among physicians. This study aimed to examine prima...
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... Previous studies in primary care settings have not compared the use of a shared decision-making tool with usual care. 20,21 Because primary care practices and providers are already handling many competing priorities aside from LCS, 22 it is critical to design tools that can be used in the real world to support primary care providers in addressing patients' informational needs efficiently. ...
... This is consistent with other shared decision-making tools that addressed knowledge. 17,18,21 However, unlike those studies, LungCARE also demonstrated increases in screening referrals relative to usual care. This suggests that implementing LungCARE in the primary care setting may be an effective model for facilitating shared decision-making and assisting patients to make choices more aligned with evidence. ...
Background:
Lung cancer screening (LCS) is recommended for individuals at high risk due to age and smoking history after a shared decision-making conversation. However, little is known about best strategies for incorporating shared decision-making, especially in a busy primary care setting.
Objective:
To develop a novel tool, Lung Cancer Assessment of Risk and Education (LungCARE) to guide LCS decisions among eligible primary care patients.
Design:
Pilot cluster randomized controlled trial of LungCARE versus usual care.
Participants:
Patients of providers in a university primary care clinic, who met criteria for LCS.
Intervention:
Providers were randomized to LungCARE intervention or control. LungCARE participants completed a computer tablet-based video assessment of lung cancer educational needs in the waiting room prior to a primary care visit. Patient and provider both received a summary handout of patient concerns and responses.
Main measures:
All eligible patients completed baseline interviews by telephone. One week after the index visit, participants completed a follow-up telephone survey that assessed patient-physician discussion of LCS, referral to and scheduling of LCS, as well as LCS knowledge and acceptability of LungCARE. Two months after index visit, we reviewed patients' electronic health records (EHRs) for evidence of a shared decision-making conversation and referral to and receipt of LCS.
Key results:
A total of 66 participants completed baseline and follow-up visits (34: LungCARE; 32: usual care). Mean age was 65.9 (± 6.0). Based on EHR review, compared to usual care, LungCARE participants were more likely to have discussed LCS with their physicians (56% vs 25%; p = 0.04) and to be referred to LCS (44% vs 13%; p < 0.02). Intervention participants were also more likely to complete LCS (32% vs 13%; p < 0.01) and had higher knowledge scores (mean score 6.5 (± 1.7) vs 5.5 (± 1.4; p < 0.01).
Conclusions:
LungCARE increased discussion, referral, and completion of LCS and improved LCS knowledge.
Clinical trial registration:
NCT03862001.
... Of the 35 studies, 12 evaluated SDM tools for colorectal cancer screening [45,48,52,54,59,62,[68][69][70]73,74,99], 11 for prostate cancer screening [46,47,51,57,59,65,66,72,73,75,78], 8 for lung cancer screening [53,55,56,60,63,64,71,77], and 3 for breast cancer screening [49,50,67]. SDM tools included video-based formats (n = 10) [45,[52][53][54]58,63,64,72,74,77], of which three were combined with a researcher-led coaching session [72], and an online DA and/or booklet [45,47]. ...
... Of the 35 studies, 12 evaluated SDM tools for colorectal cancer screening [45,48,52,54,59,62,[68][69][70]73,74,99], 11 for prostate cancer screening [46,47,51,57,59,65,66,72,73,75,78], 8 for lung cancer screening [53,55,56,60,63,64,71,77], and 3 for breast cancer screening [49,50,67]. SDM tools included video-based formats (n = 10) [45,[52][53][54]58,63,64,72,74,77], of which three were combined with a researcher-led coaching session [72], and an online DA and/or booklet [45,47]. Web-based (n = 9) [45,48,50,55,56,62,67,68,75] and paper-based formats (n = 12) were also evaluated, including the use of pamphlets, handouts, booklets, and leaflets [49,57,59,60,64,65,70,73,74,76,78,99]. ...
Simple Summary
This research was carried out to understand how shared decision-making tools, which facilitate patients and clinicians make decisions based on their values and preferences, can improve decision-making outcomes in cancer screening. The researchers further aimed to explore the preferences of patients and clinicians in terms of the tool’s content, format, and delivery strategies. The review findings showed that SDM tools for cancer screening were more helpful for people facing difficulties in understanding health information or belonging to socially disadvantaged groups, compared to those who have higher educational and socio-economic status and health/language literacy. Moreover, insights from the qualitative synthesis showed that SDM tool preferences for vulnerable populations differ with those of clinicians who are constrained by time during patient consultations. To improve SDM tools, patients and clinicians should collaborate and communicate more. By doing so, they can identify effective delivery strategies that address the needs and preferences of both parties.
Abstract
This review aimed to synthesize evidence on the effectiveness of shared decision-making (SDM) tools for cancer screening and explored the preferences of vulnerable people and clinicians regarding the specific characteristics of the SDM tools. A mixed-method convergent segregated approach was employed, which involved an independent synthesis of quantitative and qualitative data. Articles were systematically selected and screened, resulting in the inclusion and critical appraisal of 55 studies. Results from the meta-analysis revealed that SDM tools were more effective for improving knowledge, reducing decisional conflict, and increasing screening intentions among vulnerable populations compared to non-vulnerable populations. Subgroup analyses showed minimal heterogeneity for decisional conflict outcomes measured over a six-month period. Insights from the qualitative findings revealed the complexities of clinicians’ and vulnerable populations’ preferences for an SDM tool in cancer screening. Vulnerable populations highly preferred SDM tools with relevant information, culturally tailored content, and appropriate communication strategies. Clinicians, on the other hand, highly preferred tools that can be easily integrated into their medical systems for efficient use and can effectively guide their practice for cancer screening while considering patients’ values. Considering the complexities of patients’ and clinicians’ preferences in SDM tool characteristics, fostering collaboration between patients and clinicians during the creation of an SDM tool for cancer screening is essential. This collaboration may ensure effective communication about the specific tool characteristics that best support the needs and preferences of both parties.
... If a DA is used in consultation with a clinician, it can improve knowledge regarding the benefits and harms of an intervention, as found by Reuland and colleagues in their study of a lung cancer screening DA used in primary care. 25 We designed our DAs to be used in consultation with a clinician and after consumers were shown the DAs in the focus groups, they agreed that it would encourage them to have a discussion with their GP as they recognized the need to discuss the benefits and contraindications before commencing aspirin. ...
Objectives:
Australian guidelines recommend people aged 50-70 years old consider taking low-dose aspirin to reduce their risk of colorectal cancer. The aim was to design sex-specific decision aids (DAs) with clinician and consumer input, including expected frequency trees (EFTs) to communicate the risks and benefits of taking aspirin.
Methods:
Semi-structured interviews were conducted with clinicians. Focus groups were conducted with consumers. The interview schedules covered ease of comprehension, design, potential effects on decision-making, and approaches to implementation of the DAs. Thematic analysis was employed; independent coding by 2 researchers was inductive. Themes were developed through consensus between authors.
Results:
Sixty-four clinicians were interviewed over 6 months in 2019. Twelve consumers aged 50-70 years participated in two focus groups in February and March 2020. The clinicians agreed that the EFTs would be helpful to facilitate a discussion with patients but suggested including an additional estimate of the effects of aspirin on all-cause mortality. The consumers felt favourable about the DAs and suggested changes to the design and wording to ease comprehension.
Conclusion:
DAs were designed to communicate the risks and benefits of low-dose aspirin for disease prevention. The DAs are currently being trialled in general practice to determine their impact on informed decision-making and aspirin uptake.
... Since this time, multiple studies have tested the efficacy of shared decision-making processes in the education of patients regarding LDCT. Some reports have demonstrated that shared decision-making approaches with the use of decision aids to supplement standard information materials improves patient knowledge and perceived benefits of screening (55,56,61,62). However, despite improvements in patient knowledge regarding LDCT screening, some studies have shown that shared decision-making alone does not appear sufficient to uniformly improve rates of LDCT screening completion (62)(63)(64)(65). ...
... Some reports have demonstrated that shared decision-making approaches with the use of decision aids to supplement standard information materials improves patient knowledge and perceived benefits of screening (55,56,61,62). However, despite improvements in patient knowledge regarding LDCT screening, some studies have shown that shared decision-making alone does not appear sufficient to uniformly improve rates of LDCT screening completion (62)(63)(64)(65). These studies indicate that the most effective shared decision-making approaches should not only discuss screening eligibility and the risks/benefits of screening, but should also actively assess the patient's willingness and ability to undergo screening and subsequent treatment should cancer be detected (66). ...
Lung cancer screening with low-dose computed tomography (LDCT) is an effective approach for the early detection of lung cancer and the reduction of lung cancer specific mortality in high risk individuals. Despite recommendations for LDCT screening by the National Comprehensive Cancer Network (NCCN) and the United States Preventive Services Task Force, the utilization of LDCT screening in clinical practice has been low. Moreover, significant disparities in the use of LDCT have been described in underserved populations, including African American or black patients, rural patients with limited access to LDCT screening facilities, and other vulnerable patient groups with known risk factors for developing lung cancer. Several patient, provider, and healthcare systems level approaches have been proposed to mitigate lung cancer screening disparities. Such approaches include raising awareness of LDCT screening benefits and the evidence in support of LDCT screening among healthcare providers, educating patients on LDCT screening and optimizing shared decision-making approaches between patients and providers, and expanding patient access to LDCT screening through free and mobile lung cancer screening programs. As lung cancer screening utilization continues to expand in clinical practice, it will be critical to continue investigating the trends, causes, and outcomes of LDCT screening disparities in underserved populations.
... Of the 36 interventions described in the literature (Tables 1 and 2), 26 studies were conducted in the United States, 31-56 eight in the United Kingdom, 57-64 one in Japan, 65 and one in Italy. 66 Articles described 10 randomized control, 33,34,39,42,45,47,52,58,62,65 11 descriptive, 35,43,44,54,57,[59][60][61]63,64,66 seven pre and posttest, 31,37,40,46,48,49,53 three retrospective, 36,38,51 and four prospective 32,41,50,56 studies. Fifteen interventions were centered around decision-making for LCS, focusing specifically on shared decision-making (SDM) sessions 31,32,37 and, or the use of decision aids, educational tools, and outreach materials. ...
... Fifteen interventions were centered around decision-making for LCS, focusing specifically on shared decision-making (SDM) sessions 31,32,37 and, or the use of decision aids, educational tools, and outreach materials. [39][40][41][42]45,48,50,52,58,62,63,65 Interventions also focused on the use of electronic health records as a tool to reach eligible patients. Of these, two interventions prompted patients directly to seek risk assessment 33,35 and others generated clinical prompts and reminders for health care providers in the primary care setting. ...
Introduction:
Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities.
Methods:
We conducted a scoping review using the Arksey and O'Malley methodological framework to inform equitable access to LCS by illuminating knowledge and implementation gaps in interventions designed to increase the uptake of LCS. We comprehensively searched for LCS interventions (Ovid Medline, Excerpta Medica database, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus from 2000 to June 22, 2021) and included peer-reviewed articles and gray literature published in the English language that describe an intervention designed to increase the uptake of LCS, charted data using our previously published tool and conduced a health equity analysis to determine the intended-unintended and positive-negative outcomes of the interventions for populations experiencing the greatest inequities.
Results:
Our search yielded 3572 peer-reviewed articles and 54,292 pieces of gray literature. Ultimately, we included 35 peer-reviewed articles and one gray literature. The interventions occurred in the United States, United Kingdom, Japan, and Italy, focusing on shared decision-making, the use of electronic health records as reminders, patient navigation, community-based campaigns, and mobile computed tomography scanners. We developed an equity-oriented LCS framework and mapped the dimensions and outcomes of the interventions on access to LCS on the basis of approachability, acceptability, availability, affordability, and appropriateness of the intervention. No intervention was mapped across all five dimensions. Most notably, knowledge and implementation gaps were identified in dimensions of acceptability, availability, and affordability.
Conclusions:
Interventions that were most effective in improving access to LCS targeted priority populations, raised community-level awareness, tailored materials for sociocultural acceptability, did not depend on prior patient engagement/registration with the health care system, proactively considered costs related to participation, and enhanced utilization through informed decision-making.
... If a DA is used in a consultation with a clinician, it can improve knowledge regarding the bene ts and harms of an intervention, as found by Reuland and colleagues in their study of a lung cancer screening DA used in primary care. (Reuland et al., 2018) We designed our DAs to be used in a consultation with a clinician and after consumers were shown the DAs in the focus groups they agreed that it would encourage them to have a discussion with their GP as they recognised the need to discuss the bene ts and contraindications before commencing aspirin. ...
Objectives
Australian guidelines recommend people aged 50 to 70-years-old, consider taking low-dose aspirin to reduce their risk of colorectal cancer. The aim was to design sex-specific decision aids (DAs) with clinician and consumer input including expected frequency trees (EFTs) to communicate risks and benefits of taking aspirin.
Methods
Semi-structured interviews were conducted with clinicians. Focus groups were conducted with consumers. The interview schedules covered ease of comprehension, design, potential effects on decision making, and approaches to implementation of the DAs. Thematic analysis was employed; independent coding by two researchers was inductive. Themes were developed through consensus between authors.
Results
Sixty-four clinician were interviewed over six-months in 2019. Twelve consumers, aged 50 to 70 years, participated in two focus groups in February and March 2020.
... If a DA is used in a consultation with a clinician, it can improve knowledge regarding the bene ts and harms of an intervention, as found by Reuland and colleagues in their study of a lung cancer screening DA used in primary care. (Reuland et al., 2018) We designed our DAs to be used in a consultation with a clinician and after consumers were shown the DAs in the focus groups they agreed that it would encourage them to have a discussion with their GP as they recognised the need to discuss the bene ts and contraindications before commencing aspirin. ...
Objectives
Australian guidelines recommend people aged 50 to 70-years-old, consider taking low-dose aspirin to reduce their risk of colorectal cancer. The aim was to design sex-specific decision aids (DAs) with clinician and consumer input including expected frequency trees (EFTs) to communicate risks and benefits of taking aspirin.
Methods
Semi-structured interviews were conducted with clinicians. Focus groups were conducted with consumers. The interview schedules covered ease of comprehension, design, potential effects on decision making, and approaches to implementation of the DAs. Thematic analysis was employed; independent coding by two researchers was inductive. Themes were developed through consensus between authors.
Results
Sixty-four clinician were interviewed over six-months in 2019. Twelve consumers, aged 50 to 70 years, participated in two focus groups in February and March 2020.
... 8 Prior research has demonstrated increases in knowledge of benefits and harms of lung cancer screening, such as mortality benefit, false positives, and overdiagnosis. [9][10][11] In their decision memo to require use of a decision aid for lung cancer screening, CMS cites lung cancer screening as a "complex topic" with a balance of potential benefits and harms. 6 It requires decision aids to include information on specific harms including false positives and follow-up diagnostic testing. ...
... 22 The decision aid was adapted from a previously developed and tested decision aid. 9 The only addition of content to the video was a segment on incidental findings (for the intervention group only), which was 31 s in length. We developed this segment by adapting wording from health information on incidental findings and incidental findings reported from a study of a subset of NLST participants. ...
... Following viewing of the decision aid in their respective groups, both intervention and control groups indicated their agreement with a statement on their intent to pursue lung cancer screening, a previously tested survey item with a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree) (Table S2). 9 Before conducting the study, we used cognitive interviews to iteratively test and refine the wording of this item as well as the following secondary knowledge and attribute items below in (n = 6) 50-80-year-old former and current smokers. ...
Background:
The Centers for Medicare & Medicaid Services requires decision aid use for lung cancer screening (LCS) shared decision-making. However, it does not require information about incidental findings, a potential harm of screening.
Objective:
To assess the effect of incidental findings information in an LCS decision aid on screening intent as well as knowledge and valuing of screening benefits and harms.
Design:
Randomized controlled trial conducted online between July 16, 2020, and August 22, 2020.
Participants:
Adults 55-80 years, eligible for LCS.
Intervention:
LCS video decision aid including information on incidental findings or a control video decision aid.
Main measures:
Intent to undergo LCS; knowledge regarding the benefit and harms of LCS using six knowledge questions; and valuing of six benefits and harms using rating (1-5 scale, 5 most important) and ranking (ranked 1-6) exercises.
Key results:
Of 427 eligible individuals approached, 348 (83.1%) completed the study (173 intervention, 175 control). Mean age was 64.5 years, 48.6% were male, 73.0% white, 76.3% with less than a college degree, and 64.1% with income < $50,000. There was no difference between the intervention and controls in percentage intending to pursue screening (70/173, 40.5% vs 73/175, 41.7%, diff 1.2%, 95% CI - 9.1 to 11.5%, p = 0.81). Intervention participants had a higher percentage of correct answers for the incidental findings knowledge than controls (164/173, 94.8% vs 129/175, 73.7%, 95% CI - 28.4 to - 13.8%, p < 0.01). Incidental findings had the fifth highest mean importance rating (4.0 ± 1.1) and the third highest mean ranking (3.6 ± 1.5). There was no difference in mean rating or ranking of incidental findings between intervention and control groups (rating 4.0 vs 3.9, diff 0.1, 95% CI - 0.2, 0.3, p = 0.51; ranking 3.6 vs 3.6, diff 0.02, 95% CI - 0.3, 0.3, p = 0.89).
Conclusions:
Incidental findings information in a LCS decision aid did not affect LCS intent, but it resulted in more informed individuals regarding these findings. In formulating screening preferences, incidental findings were less important than other benefits and harms.
Trial registration:
ClinicalTrials.gov identifier: NCT04432753.
... This case study illustrates the importance of researcher support for a practice-initiated project in developing strong research/practice partnerships. Through their decade-long partnership with this clinic, CPCRN researchers have engaged clinic stakeholders in multiple researcher-initiated projects [49,50]. screening. ...
Background
In several recent articles, authors have called for aligning the fields of implementation and improvement science. In this paper, we call for implementation science to also align with improvement practice . Multiple implementation scholars have highlighted the importance of designing implementation strategies to fit the existing culture, infrastructure, and practice of a healthcare system. Worldwide, healthcare systems are adopting improvement models as their primary approach to improving healthcare delivery and outcomes. The prevalence of improvement models raises the question of how implementation scientists might best align their efforts with healthcare systems’ existing improvement infrastructure and practice.
Main body
We describe three challenges and five benefits to aligning implementation science and improvement practice. Challenges include (1) use of different models, terminology, and methods, (2) a focus on generalizable versus local knowledge, and (3) limited evidence in support of the effectiveness of improvement tools and methods. We contend that implementation science needs to move beyond these challenges and work toward greater alignment with improvement practice. Aligning with improvement practice would benefit implementation science by (1) strengthening research/practice partnerships, (2) fostering local ownership of implementation, (3) generating practice-based evidence, (4) developing context-specific implementation strategies, and (5) building practice-level capacity to implement interventions and improve care. Each of these potential benefits is illustrated in a case study from the Centers for Disease Control and Prevention’s Cancer Prevention and Control Research Network.
Conclusion
To effectively integrate evidence-based interventions into routine practice, implementation scientists need to align their efforts with the improvement culture and practice that is driving change within healthcare systems worldwide. This paper provides concrete examples of how researchers have aligned implementation science with improvement practice across five implementation projects.
... Observational studies suggest that an SDM visit may improve screening knowledge and lead to high levels of patient satisfaction whether inperson or telephonic, and that diverse populations think decision aids are useful and able to increase patient knowledge about LDCT screening and its tradeoffs. [97][98][99][100] Detailed initial presentations of information during SDM may not be feasible for lung cancer screening in routine primary care practice. 101,102 Lack of time is a consistent barrier to SDM in primary care 101 and has been reported as a potential barrier to SDM for LDCT screening. ...
Background
Low-dose chest CT screening for lung cancer has become a standard of care in the United States, in large part due to the results of the National Lung Screening Trial. Additional evidence supporting the net benefit of low-dose chest CT screening for lung cancer, as well as 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 PICO (population, intervention, comparator, and outcome) format to address the benefit and harms of low-dose CT screening, as well as 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 GRADE approach. Meta-analyses were performed where appropriate. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and un-graded 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 7 graded recommendations and 9 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.
