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Lewis JA, Samuels LR, Weems J, Park D, Winter R, Lindsell CJ, Callaway-Lane C, Audet C, Slatore CG, Wiener RS, Dittus RS, Kripalani S, Yankelevitz DF, Henschke CI, Moghanaki D, Matheny ME, Vogus TJ, Roumie CL, Spalluto LB. The Association of Organizational Readiness With Lung Cancer Screening Utilization. Am J Prev Med 2023; 65:844-853. [PMID: 37224985 PMCID: PMC10592591 DOI: 10.1016/j.amepre.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Lung cancer screening is widely underutilized. Organizational factors, such as readiness for change and belief in the value of change (change valence), may contribute to underutilization. The aim of this study was to evaluate the association between healthcare organizations' preparedness and lung cancer screening utilization. METHODS Investigators cross-sectionally surveyed clinicians, staff, and leaders at10 Veterans Affairs from November 2018 to February 2021 to assess organizational readiness to implement change. In 2022, investigators used simple and multivariable linear regression to evaluate the associations between facility-level organizational readiness to implement change and change valence with lung cancer screening utilization. Organizational readiness to implement change and change valence were calculated from individual surveys. The primary outcome was the proportion of eligible Veterans screened using low-dose computed tomography. Secondary analyses assessed scores by healthcare role. RESULTS The overall response rate was 27.4% (n=1,049), with 956 complete surveys analyzed: median age of 49 years, 70.3% female, 67.6% White, 34.6% clinicians, 61.1% staff, and 4.3% leaders. For each 1-point increase in median organizational readiness to implement change and change valence, there was an associated 8.4-percentage point (95% CI=0.2, 16.6) and a 6.3-percentage point increase in utilization (95% CI= -3.9, 16.5), respectively. Higher clinician and staff median scores were associated with increased utilization, whereas leader scores were associated with decreased utilization after adjusting for other roles. CONCLUSIONS Healthcare organizations with higher readiness and change valence utilized more lung cancer screening. These results are hypothesis generating. Future interventions to increase organizations' preparedness, especially among clinicians and staff, may increase lung cancer screening utilization.
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Affiliation(s)
- Jennifer A Lewis
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Medical Service, VA Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, Tennessee; Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.
| | - Lauren R Samuels
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacy Weems
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel Park
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Winter
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carol Callaway-Lane
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Medical Service, VA Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn Audet
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care (CIVIC), Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon; Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon; VA National Center for Lung Cancer Screening (NCLCS), Veterans Health Administration, Washington, District of Columbia
| | - Renda Soylemez Wiener
- VA National Center for Lung Cancer Screening (NCLCS), Veterans Health Administration, Washington, District of Columbia; Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts; The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert S Dittus
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Yankelevitz
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Claudia I Henschke
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York; VA Phoenix Health Care System, Phoenix, Arizona
| | - Drew Moghanaki
- Radiation Oncology Service, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael E Matheny
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee
| | - Christianne L Roumie
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Lucy B Spalluto
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Vanderbilt-Ingram Cancer Center, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Lewis JA, Bonnet K, Schlundt DG, Byerly S, Lindsell CJ, Henschke CI, Yankelevitz DF, York SJ, Hendler F, Dittus RS, Vogus TJ, Kripalani S, Moghanaki D, Audet CM, Roumie CL, Spalluto LB. Rural barriers and facilitators of lung cancer screening program implementation in the veterans health administration: a qualitative study. Front Health Serv 2023; 3:1209720. [PMID: 37674596 PMCID: PMC10477991 DOI: 10.3389/frhs.2023.1209720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/04/2023] [Indexed: 09/08/2023]
Abstract
Introduction To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members. Methods Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation. Results A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior. Discussion Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings.
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Affiliation(s)
- Jennifer A. Lewis
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Qualitative Research Core, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David G. Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Qualitative Research Core, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susan Byerly
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Claudia I. Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States
- Veterans Health Administration—Phoenix VA Health Care System, Radiology Service, Phoenix, AZ, United States
| | - David F. Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States
| | - Sally J. York
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Fred Hendler
- Rex Robley VA Medical Center, Medicine Service, Louisville, KY, United States
| | - Robert S. Dittus
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Timothy J. Vogus
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN, United States
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Drew Moghanaki
- Veterans Health Administration—Greater Los Angeles Veterans Affairs Medical Center, Radiation Oncology Service, Los Angeles, CA, United States
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Carolyn M. Audet
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christianne L. Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lucy B. Spalluto
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Qiao EM, Voora RS, Nalawade V, Kotha NV, Qian AS, Nelson TJ, Durkin M, Vitzthum LK, Murphy JD, Stewart TF, Rose BS. Evaluating the clinical trends and benefits of low-dose computed tomography in lung cancer patients. Cancer Med 2021; 10:7289-7297. [PMID: 34528761 PMCID: PMC8525167 DOI: 10.1002/cam4.4229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/30/2021] [Accepted: 07/31/2021] [Indexed: 12/19/2022] Open
Abstract
Background Despite guideline recommendations, utilization of low‐dose computed tomography (LDCT) for lung cancer screening remains low. The driving factors behind these low rates and the real‐world effect of LDCT utilization on lung cancer outcomes remain limited. Methods We identified patients diagnosed with non‐small cell lung cancer (NSCLC) from 2015 to 2017 within the Veterans Health Administration. Multivariable logistic regression assessed the influence of LDCT screening on stage at diagnosis. Lead time correction using published LDCT lead times was performed. Cancer‐specific mortality (CSM) was evaluated using Fine–Gray regression with non‐cancer death as a competing risk. A lasso machine learning model identified important predictors for receiving LDCT screening. Results Among 4664 patients, mean age was 67.8 with 58‐month median follow‐up, 95% CI = [7–71], and 118 patients received ≥1 screening LDCT before NSCLC diagnosis. From 2015 to 2017, LDCT screening increased (0.1%–6.6%, mean = 1.3%). Compared with no screening, patients with ≥1 LDCT were more than twice as likely to present with stage I disease at diagnosis (odds ratio [OR] 2.16 [95% CI 1.46–3.20]) and less than half as likely to present with stage IV (OR 0.38 [CI 0.21–0.70]). Screened patients had lower risk of CSM even after adjusting for LDCT lead time (subdistribution hazard ratio 0.60 [CI 0.42–0.85]). The machine learning model achieved an area under curve of 0.87 and identified diagnosis year and region as the most important predictors for receiving LDCT. White, non‐Hispanic patients were more likely to receive LDCT screening, whereas minority, older, female, and unemployed patients were less likely. Conclusions Utilization of LDCT screening is increasing, although remains low. Consistent with randomized data, LDCT‐screened patients were diagnosed at earlier stages and had lower CSM. LDCT availability appeared to be the main predictor of utilization. Providing access to more patients, including those in diverse racial and socioeconomic groups, should be a priority.
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Affiliation(s)
- Edmund M Qiao
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Rohith S Voora
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Nikhil V Kotha
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Alexander S Qian
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Tyler J Nelson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Michael Durkin
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Tyler F Stewart
- Division of Hematology-Oncology, Department of Internal Medicine, University of California San Diego, La Jolla, California, USA
| | - Brent S Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
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