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Ackland PE, Hagedorn HJ, Kenny ME, Salameh HA, Kehle-Forbes SM, Gustavson AM, Karimzadeh LE, Meis LA. Using brief reflections to capture and evaluate end-user engagement: a case example using the COMPASS study. BMC Med Res Methodol 2024; 24:103. [PMID: 38698315 PMCID: PMC11065677 DOI: 10.1186/s12874-024-02222-5] [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: 06/27/2023] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Use of participatory research methods is increasing in research trials. Once partnerships are established with end-users, there is less guidance about processes research teams can use to successfully incorporate end-user feedback. The current study describes the use of a brief reflections process to systematically examine and evaluate the impact of end-user feedback on study conduct. METHODS The Comparative Effectiveness of Trauma-Focused and Non-Trauma- Focused Treatment Strategies for PTSD among those with Co-Occurring SUD (COMPASS) study was a randomized controlled trial to determine the effectiveness of trauma-focused psychotherapy versus non-trauma-focused psychotherapy for Veterans with co-occurring posttraumatic stress disorder and substance use disorder who were entering substance use treatment within the Department of Veterans Affairs. We developed and paired a process of "brief reflections" with our end-user engagement methods as part of a supplemental evaluation of the COMPASS study engagement plan. Brief reflections were 30-minute semi-structured discussions with the COMPASS Team following meetings with three study engagement panels about feedback received regarding study issues. To evaluate the impact of panel feedback, 16 reflections were audio-recorded, transcribed, rapidly analyzed, and integrated with other study data sources. RESULTS Brief reflections revealed that the engagement panels made recommended changes in eight areas: enhancing recruitment; study assessment completion; creating uniformity across Study Coordinators; building Study Coordinator connection to Veteran participants; mismatch between study procedures and clinical practice; therapist skill with patients with active substance use; therapist burnout; and dissemination of study findings. Some recommendations positively impact study conduct while others had mixed impact. Reflections were iterative and led to emergent processes that included revisiting previously discussed topics, cross-pollination of ideas across panels, and sparking solutions amongst the Team when the panels did not make any recommendations or recommendations were not feasible. CONCLUSIONS When paired with end-user engagement methods, brief reflections can facilitate systematic examination of end-user input, particularly when the engagement strategy is robust. Reflections offer a forum of accountability for researchers to give careful thought to end-user recommendations and make timely improvements to the study conduct. Reflections can also facilitate evaluation of these recommendations and reveal end-user-driven strategies that can effectively improve study conduct. TRIAL REGISTRATION ClinicalTrials.gov (NCT04581434) on October 9, 2020; https://clinicaltrials.gov/ct2/show/study/NCT04581434?term=NCT04581434&draw=2&rank=1 .
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA.
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | - Hildi J Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA
- Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, 2312 South 6th Street, Minneapolis, MN, 55454, USA
- Center of Excellence in Substance Addiction Treatment and Education, Seattle Division, VA Puget Sound Healthcare System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - Marie E Kenny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Hope A Salameh
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Shannon M Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Women's Health Sciences Division at VA Boston, National Center for PTSD, 150 South Huntington Street, Boston, MA, 02130, USA
| | - Allison M Gustavson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Leyla E Karimzadeh
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Laura A Meis
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Women's Health Sciences Division at VA Boston, National Center for PTSD, 150 South Huntington Street, Boston, MA, 02130, USA
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Maurice NM, Tanner NT. Lung cancer screening at the VA: Past, present and future. Semin Oncol 2022; 49:S0093-7754(22)00041-0. [PMID: 35831214 DOI: 10.1053/j.seminoncol.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/04/2022] [Indexed: 11/11/2022]
Abstract
Lung cancer is responsible for more deaths annually in the United States than breast, prostate and colon cancers combined. Lung cancer screening with annual low-dose computed tomography reduces lung cancer mortality in high-risk patients through early detection. The incidence of lung cancer is higher in the veteran population compared to the general population due, in part, to the prevalence of tobacco use. Early detection of lung cancer is therefore an important goal of the Veterans Health Administration (VHA), the largest integrated health care system in the United States. The following will review previous and current initiatives undertaken by the VHA to implement and expand access to lung cancer screening and will highlight target areas of interest to improve uptake and quality of lung cancer screening. Through these initiatives and programs, the VHA aims to provide high quality and equitable access to lung cancer screening for all Veterans that incorporates research that will improve outcomes and potentially inform and optimize the practice of Lung cancer screening across the United States.
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Affiliation(s)
- Nicholas M Maurice
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA, U.S.A.; Atlanta Veterans Affairs Health Care System, Decatur, GA.
| | - Nichole T Tanner
- Ralph H. Johnson Veterans Affairs Hospital, Health Equity and Rural Outreach Innovation Center (HEROIC), Charleston, SC, U.S.A.; Medical University of South Carolina, Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Charleston, SC, U.S.A
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Leveraging the ExpandNet framework and operational partnerships to scale-up brief Cognitive Behavioral Therapy in VA primary care clinics. J Clin Transl Sci 2022; 6:e95. [PMID: 36003211 PMCID: PMC9393574 DOI: 10.1017/cts.2022.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/25/2022] [Accepted: 07/15/2022] [Indexed: 11/09/2022] Open
Abstract
Evidence-based psychotherapies (EBPs) are underused in health care settings. Aligning implementation of EBPs with the needs of health care leaders (i.e., operational stakeholders) can potentially accelerate their uptake into routine practice. Operational stakeholders (such as hospital leaders, clinical directors, and national program officers) can influence development and oversight of clinical programs as well as policy directives at local, regional, and national levels. Thus, engaging these stakeholders during the implementation and dissemination of EBPs is critical when targeting wider use in health care settings. This article describes how research–operations partnerships were leveraged to increase implementation of an empirically supported psychotherapy – brief Cognitive Behavioral Therapy (brief CBT) – in Veterans Health Administration (VA) primary care settings. The partnered implementation and dissemination efforts were informed by the empirically derived World Health Organization’s ExpandNet framework. A steering committee was formed and included several VA operational stakeholders who helped align the brief CBT program with the implementation needs of VA primary care settings. During the first 18 months of the project, partnerships facilitated rapid implementation of brief CBT at eight VA facilities, including training of 12 providers who saw 120 patients, in addition to expanded program elements to better support sustainability (e.g., train-the-trainer procedures).
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Nash DM, Bhimani Z, Rayner J, Zwarenstein M. Learning health systems in primary care: a systematic scoping review. BMC FAMILY PRACTICE 2021; 22:126. [PMID: 34162336 PMCID: PMC8223335 DOI: 10.1186/s12875-021-01483-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/10/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are operating, and potential challenges and solutions. METHODS We completed a scoping review by systematically searching OVID Medline®, Embase®, IEEE Xplore®, and reviewing specific journals from 2007 to 2020. We also completed a Google search to identify gray literature. RESULTS We reviewed 1924 articles through our database search and 51 articles from other sources, from which we identified 21 unique learning health systems based on 62 data sources. Only one of these learning health systems was implemented exclusively in a primary care setting, where all others were integrated health systems or networks that also included other care settings. Eighteen of the 21 were in the United States. Examples of how these learning health systems were being used included real-time clinical surveillance, quality improvement initiatives, pragmatic trials at the point of care, and decision support. Many challenges and potential solutions were identified regarding data, sustainability, promoting a learning culture, prioritization processes, involvement of community, and balancing quality improvement versus research. CONCLUSIONS We identified 21 learning health systems, which all appear at an early stage of development, and only one was primary care only. We summarized and provided examples of integrated health systems and data networks that can be considered early models in the growing global movement to advance learning health systems in primary care.
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Affiliation(s)
- Danielle M Nash
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada. .,ICES, London, ON, Canada.
| | - Zohra Bhimani
- Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Jennifer Rayner
- Centre for Studies in Family Medicine, Western University, London, ON, Canada.,Department of Research and Evaluation, Alliance for Healthier Communities, Toronto, ON, Canada
| | - Merrick Zwarenstein
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Centre for Studies in Family Medicine, Western University, London, ON, Canada.,ICES, Toronto, ON, Canada
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5
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Smigelsky MA, Nieuwsma JA, Meador K, Vega RJ, Henderson B, Jackson GL. Dynamic Diffusion Network: Advancing moral injury care and suicide prevention using an innovative model. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100440. [PMID: 32919579 PMCID: PMC7405892 DOI: 10.1016/j.hjdsi.2020.100440] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/24/2020] [Accepted: 05/23/2020] [Indexed: 11/19/2022]
Abstract
Healthcare providers across a wide variety of settings face a common challenge: the need to provide real time care for complex problems that are not adequately addressed by existing protocols. In response to these intervention gaps, frontline providers may utilize existing evidence to develop new approaches that are tailored to specific problems. It is imperative that such approaches undergo some form of evaluation, ensuring quality control while permitting ongoing adaptation and refinement. “Dynamic diffusion” is an innovative approach to intervention improvement and dissemination whereby care practices are delivered and continuously evaluated under real-world conditions as part of a structured network experience. This “dynamic diffusion network” (DDN) promotes cross-pollination of ideas and shared learning to generate relatively rapid improvements in care. The pilot Mental Health and Chaplaincy DDN was developed to advance suicide prevention efforts and moral injury care practices being conducted by 13 chaplain-mental health professional teams across the Veterans Health Administration. Lessons learned from the pilot DDN include the importance of the following: geographic and cultural diversity among innovation collaborators to ensure the broadest possible relevance of solutions; leadership support to facilitate engagement of frontline providers in quality improvement efforts; and participation in a community of practice to motivate providers and offer opportunities for direct collaboration and cross-pollination of ideas.
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Affiliation(s)
- Melissa A Smigelsky
- Mental Health and Chaplaincy, Department of Veterans Affairs, Durham, NC, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Jason A Nieuwsma
- Mental Health and Chaplaincy, Department of Veterans Affairs, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Keith Meador
- Mental Health and Chaplaincy, Department of Veterans Affairs, Durham, NC, USA; Departments of Psychiatry and Health Policy, Center for Biomedical Ethics and Society, Vanderbilt Divinity School, Vanderbilt University, Nashville, TN, USA
| | - Ryan J Vega
- VHA Innovation Ecosystem/Diffusion of Excellence, Department of Veterans Affairs, Washington, DC, USA
| | - Blake Henderson
- VHA Innovation Ecosystem/Diffusion of Excellence, Department of Veterans Affairs, Washington, DC, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA; Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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Lieu TA, Madvig PR. Strategies for Building Delivery Science in an Integrated Health Care System. J Gen Intern Med 2019; 34:1043-1047. [PMID: 30684194 PMCID: PMC6544703 DOI: 10.1007/s11606-018-4797-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 09/25/2018] [Accepted: 12/06/2018] [Indexed: 12/23/2022]
Abstract
Health systems today have increasing opportunities and imperatives to conduct delivery science, which is applied research that evaluates clinical or organizational practices that systems can implement or encourage. Examples include research on eliminating racial/ethnic disparities in hypertension management and on identifying the types of patients who can successfully use video visits. Clinical leaders and researchers often face barriers to delivery science, including limited funding, insufficient leadership support, lack of engagement between operational and research leaders, limited pools of research expertise, and lack of pathways to identify and develop ideas. We describe five key strategies we employed to address these barriers and develop a portfolio of delivery science programs in Kaiser Permanente Northern California. This portfolio now includes small and medium-sized grant programs, training programs for postdoctoral research fellows and experienced physician researchers, and a dedicated team that partners with clinicians to develop high-priority ideas and conduct small projects. Most of our approaches are consistent with frameworks used to develop delivery science by other health systems; some are innovative. Most of these strategies are adaptable by other health systems prepared to make long-range organizational commitments to mechanisms that foster partnerships between clinical leaders and researchers.
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Affiliation(s)
- Tracy A Lieu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- The Permanente Medical Group, Oakland, CA, USA.
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Readiness for Implementation of Lung Cancer Screening. A National Survey of Veterans Affairs Pulmonologists. Ann Am Thorac Soc 2017; 13:1794-1801. [PMID: 27409524 DOI: 10.1513/annalsats.201604-294oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE To mitigate the potential harms of screening, professional societies recommend that lung cancer screening be conducted in multidisciplinary programs with the capacity to provide comprehensive care, from screening through pulmonary nodule evaluation to treatment of screen-detected cancers. The degree to which this standard can be met at the national level is unknown. OBJECTIVES To assess the readiness of clinical facilities in a national healthcare system for implementation of comprehensive lung cancer screening programs, as compared with the ideal described in policy recommendations. METHODS This was a cross-sectional, self-administered survey of staff pulmonologists in pulmonary outpatient clinics in Veterans Health Administration facilities. MEASUREMENTS AND MAIN RESULTS The facility-level response rate was 84.1% (106 of 126 facilities with pulmonary clinics); 88.7% of facilities showed favorable provider perceptions of the evidence for lung cancer screening, and 73.6% of facilities had a favorable provider-perceived local context for screening implementation. All elements of the policy-recommended infrastructure for comprehensive screening programs were present in 36 of 106 facilities (34.0%); the most common deficiencies were the lack of on-site positron emission tomography scanners or radiation oncology services. Overall, 26.5% of Veterans Health Administration facilities were ideally prepared for lung cancer screening implementation (44.1% if the policy recommendations for on-site positron emission tomography scanners and radiation oncology services were waived). CONCLUSIONS Many facilities may be less than ideally positioned for the implementation of comprehensive lung cancer screening programs. To ensure safe, effective screening, hospitals may need to invest resources or coordinate care with facilities that can offer comprehensive care for screening through downstream evaluation and treatment of screen-detected cancers.
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Jackson GL, Roumie CL, Rakley SM, Kravetz JD, Kirshner MA, Del Monte PS, Bowen ME, Oddone EZ, Weiner BJ, Shaw RJ, Bosworth HB. Linkage between theory-based measurement of organizational readiness for change and lessons learned conducting quality improvement-focused research. Learn Health Syst 2017; 1:e10013. [PMID: 31245556 PMCID: PMC6516710 DOI: 10.1002/lrh2.10013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 07/28/2016] [Accepted: 08/18/2016] [Indexed: 11/21/2022] Open
Abstract
Organizations have different levels of readiness to implement change in the patient care process. The Hypertension Telemedicine Nurse Implementation Project for Veterans (HTN-IMPROVE) is an example of an innovation that seeks to enhance delivery of care for patients with hypertension. We describe the link between organizational readiness for change (ORC), assessed as the project began, and barriers and facilitators occurring during the process of implementing a primary care innovation. Each of 3 Veterans Affairs medical centers provided a half-time nurse and implemented a nurse-delivered, telephone-based self-management support program for patients with uncontrolled hypertension. As the program was starting, we assessed the ORC and factors associated with ORC. On the basis of consensus of medical center and research partners, we enumerated implementation process barriers and facilitators. The primary ORC barrier was unclear long-term commitment of nursing to provide continued resources to the program. Three related barriers included the need to address: (1) competing organizational demands, (2) differing mechanisms to integrate new interventions into existing workload, and (3) methods for referring patients to disease and self-management support programs. Prior to full implementation, however, stakeholders identified a high level of commitment to conduct nurse-delivered interventions fully using their skills. There was also a significant commitment from the core implementation team and a desire to improve patient outcomes. These facilitators were observed during the implementation of HTN-IMPROVE. As demonstrated by the link between barriers to and facilitators of implementation anticipated though the evaluation of ORC and what was actually observed during the process of implementation, this project demonstrates the practical utility of assessing ORC prior to embarking on the implementation of significant new clinical innovations.
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Affiliation(s)
- George L. Jackson
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
| | - Christianne L. Roumie
- VA Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Health Services Research & DevelopmentVA Tennessee Valley Healthcare SystemNashvilleTN
- Department of MedicineVanderbilt UniversityNashvilleTN
| | - Susan M. Rakley
- Division of General Internal MedicineDuke UniversityDurhamNC
- Durham VA Medical CenterDurhamNC
| | - Jeffrey D. Kravetz
- VA Connecticut Healthcare SystemWest HavenCT
- School of MedicineYale UniversityNew HavenCT
| | - Miriam A. Kirshner
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
| | | | - Michael E. Bowen
- Departments of Internal Medicine, Clinical Sciences, and PediatricsUniversity of Texas Southwestern Medical CenterDallasTX
| | - Eugene Z. Oddone
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
| | - Bryan J. Weiner
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNC
| | - Ryan J. Shaw
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- School of NursingDuke UniversityDurhamNC
| | - Hayden B. Bosworth
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
- School of NursingDuke UniversityDurhamNC
- Department of Psychiatry and Behavioral SciencesDuke UniversityDurhamNC
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Kinsinger LS, Anderson C, Kim J, Larson M, Chan SH, King HA, Rice KL, Slatore CG, Tanner NT, Pittman K, Monte RJ, McNeil RB, Grubber JM, Kelley MJ, Provenzale D, Datta SK, Sperber NS, Barnes LK, Abbott DH, Sims KJ, Whitley RL, Wu RR, Jackson GL. Implementation of Lung Cancer Screening in the Veterans Health Administration. JAMA Intern Med 2017; 177:399-406. [PMID: 28135352 DOI: 10.1001/jamainternmed.2016.9022] [Citation(s) in RCA: 241] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The US Preventive Services Task Force recommends annual lung cancer screening (LCS) with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years. There is little published experience regarding implementing this recommendation in clinical practice. OBJECTIVES To describe organizational- and patient-level experiences with implementing an LCS program in selected Veterans Health Administration (VHA) hospitals and to estimate the number of VHA patients who may be candidates for LCS. DESIGN, SETTING, AND PARTICIPANTS This clinical demonstration project was conducted at 8 academic VHA hospitals among 93 033 primary care patients who were assessed on screening criteria; 2106 patients underwent LCS between July 1, 2013, and June 30, 2015. INTERVENTIONS Implementation Guide and support, full-time LCS coordinators, electronic tools, tracking database, patient education materials, and radiologic and nodule follow-up guidelines. MAIN OUTCOMES AND MEASURES Description of implementation processes; percentages of patients who agreed to undergo LCS, had positive findings on results of low-dose computed tomographic scans (nodules to be tracked or suspicious findings), were found to have lung cancer, or had incidental findings; and estimated number of VHA patients who met the criteria for LCS. RESULTS Of the 4246 patients who met the criteria for LCS, 2452 (57.7%) agreed to undergo screening and 2106 (2028 men and 78 women; mean [SD] age, 64.9 [5.1] years) underwent LCS. Wide variation in processes and patient experiences occurred among the 8 sites. Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer. A variety of incidental findings, such as emphysema, other pulmonary abnormalities, and coronary artery calcification, were noted on the scans of 857 patients (40.7%). CONCLUSIONS AND RELEVANCE It is estimated that nearly 900 000 of a population of 6.7 million VHA patients met the criteria for LCS. Implementation of LCS in the VHA will likely lead to large numbers of patients eligible for LCS and will require substantial clinical effort for both patients and staff.
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Affiliation(s)
- Linda S Kinsinger
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Charles Anderson
- Veterans Health Administration National Radiology Program Office, Durham, North Carolina
| | - Jane Kim
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Martha Larson
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Stephanie H Chan
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Heather A King
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Kathryn L Rice
- Department of Medicine, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Christopher G Slatore
- Department of Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Nichole T Tanner
- Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
| | - Kathleen Pittman
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Robert J Monte
- Pittsburgh Veterans Engineering Resource Center, Pittsburgh, Pennsylvania
| | - Rebecca B McNeil
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Janet M Grubber
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Michael J Kelley
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Veterans Health Administration National Oncology Program, Durham, North Carolina
| | - Dawn Provenzale
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Santanu K Datta
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Nina S Sperber
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lottie K Barnes
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
| | - David H Abbott
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
| | - Kellie J Sims
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
| | - Richard L Whitley
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
| | - R Ryanne Wu
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - George L Jackson
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
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10
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Evaluations of Implementation at Early-Adopting Lung Cancer Screening Programs: Lessons Learned. Chest 2017; 152:70-80. [PMID: 28223153 DOI: 10.1016/j.chest.2017.02.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/24/2016] [Accepted: 02/01/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Guidelines recommend lung cancer screening (LCS), and it is currently being adopted nationwide. The American College of Chest Physicians advises inclusion of specific programmatic components to ensure high-quality screening. However, little is known about how LCS has been implemented in practice. We sought to evaluate the experience of early-adopting programs, characterize barriers faced, and identify strategies to achieve successful implementation. METHODS We performed qualitative evaluations of LCS implementation at three Veterans Administration facilities, conducting semistructured interviews with key staff (n = 29). Guided by the Promoting Action on Research Implementation in Health Services framework, we analyzed transcripts using principals of grounded theory. RESULTS Programs successfully incorporated most recommended elements of LCS, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of pulmonary nodules detected by screening and difficulty obtaining primary care "buy-in." To manage workload, programs used nurse coordinators to actively maintain screening registries, held multidisciplinary conferences that generated explicit management recommendations, and rolled out implementation in a staged fashion. Successful strategies to engage primary care providers included educational sessions, audit and feedback of local outcomes, and assisting with and assigning clear responsibility for nodule evaluation. Capitalizing on pre-existing relationships and including a designated program champion helped facilitate intradisciplinary communication. CONCLUSIONS Lung cancer screening implementation is a complex undertaking requiring coordination at many levels. The insight gained from evaluation of these early-adopting programs may inform subsequent design and implementation of LCS programs.
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11
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Lillie SE, Fu SS, Fabbrini AE, Rice KL, Clothier B, Nelson DB, Doro EA, Moughrabieh MA, Partin MR. What factors do patients consider most important in making lung cancer screening decisions? Findings from a demonstration project conducted in the Veterans Health Administration. Lung Cancer 2016; 104:38-44. [PMID: 28212998 DOI: 10.1016/j.lungcan.2016.11.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 11/17/2016] [Accepted: 11/28/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The National Lung Screening Trial recently reported that annual low-dose computed tomography screening is associated with decreased lung cancer mortality in high-risk smokers. This study sought to identify the factors patients consider important in making lung cancer screening (LCS) decisions, and explore variations by patient characteristics and LCS participation. MATERIAL AND METHODS This observational survey study evaluated the Minneapolis VA LCS Clinical Demonstration Project in which LCS-eligible Veterans (N=1388) were randomized to either Direct LCS Invitation (mailed with decision aid, N=926) or Usual Care (provider referral, N=462). We surveyed participants three months post-randomization (response rate 44%) and report the proportion of respondents rating eight decision-making factors (benefits, harms, and neutral factors) as important by condition, patient characteristics, and LCS completion. RESULTS Overall, the most important factor was personal risk of lung cancer and the least important factor was health risks from LCS. The reported importance varied by patient characteristics, including smoking status, health status, and education level. Overall, the potential harms of LCS were reported less important than the benefits or the neutral decision-making factors. Exposure to Direct LCS Invitation (with decision aid) increased Veterans' attention to specific decision-making factors; compared to Usual Care respondents, a larger proportion of Direct LCS Invitation respondents rated the chance of false-positive results, LCS knowledge, LCS convenience, and anxiety as important. Those completing LCS considered screening harms less important, with the exception of incidental findings. CONCLUSION Decision tools influence Veterans' perceptions about LCS decision-making factors. As the factors important to LCS decision making vary by patient characteristics, targeted materials for specific subgroups may be warranted. Attention should be paid to how LCS incidental findings are communicated.
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Affiliation(s)
- Sarah E Lillie
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA; Division of General Internal Medicine, University of Minnesota, Minneapolis, USA.
| | - Steven S Fu
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA; Division of General Internal Medicine, University of Minnesota, Minneapolis, USA
| | - Angela E Fabbrini
- Division of Pulmonology, Minneapolis VA Health Care System, Minneapolis, USA
| | - Kathryn L Rice
- Division of Pulmonology, Minneapolis VA Health Care System, Minneapolis, USA; Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, USA
| | - Barbara Clothier
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA
| | - David B Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA; Division of General Internal Medicine, University of Minnesota, Minneapolis, USA
| | - Elizabeth A Doro
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA
| | | | - Melissa R Partin
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA; Division of General Internal Medicine, University of Minnesota, Minneapolis, USA
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