Richard M. Hoffman, MD, MPHa,b,c; Julie A. Lang, RN, BSN, MBAd; George J. Baileyd; James A. Merchant, MSd; Aaron S. Seaman, PhDa,b,c; Elizabeth A. Newbury, MAd; Rolando Sanchez, MD, MSa,b; Robert J. Volk, PhDe; Lisa M. Lowenstein, PhDe; Sarah L. Averill, MDf
Correspondence: Richard M. Hoffman (richard-m-hoffman @uiowa.edu)
aIowa City Veterans Affairs Medical Center, Iowa
bUniversity of Iowa Carver College of Medicine, Iowa City
cHolden Comprehensive Cancer Center, University of Iowa, Iowa City
dVeterans Rural Health Resource Center, Office of Rural Health, Veterans Health Administration, Iowa City, Iowa
eThe University of Texas MD Anderson Cancer Center, HoustonfRoswell Park Comprehensive Cancer Center, Buffalo, New York
Author disclosures
The study was supported by a grant from the Office of Rural Health (ORH) (NOMAD #03526) awarded to Richard Hoffman. The funding body did not play a role in the design of the study or the collection and analysis of data. Lisa Lowenstein and Robert Volk are supported by a grant funded by the National Institutes of Health, National Cancer Institute, USA, under award number P30CA016672, using the Shared Decision-Making Core, and by a grant from the Cancer Prevention and Research Institute of Texas (RP160674). None of the other authors have any disclosures. None of the authors have conflicts of interest with the work.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Ethics and consent
The University of Iowa Hawk Institutional Review Board determined that this study did not include research on human subjects and was exempt from oversight.
We faced some notable implementation challenges. The COVID-19 pandemic was extremely disruptive to LCS as it was to all health care. In addition, screening workflow processes were hampered by a lack of clinical reminders, which ideally would trigger for clinicians based on the tobacco history. The absence of this reminder meant that numerous patients were found to be ineligible for screening. We have a long-standing lung nodule clinic, and clinicians were confused about whether to order a surveillance imaging for an incidental nodule or a screening LDCT.
The radiology service was able to update order sets in CPRS to help guide clinicians in distinguishing indications and prerequisites for enrolling in LCS. This helped reduce the number of inappropriate orders and crossover orders between the VISN nodule tracking program and the LCS program.
Our results were preliminary and based on a small sample. We did not survey all veterans who underwent SDM, though the response rate was 79% and patient characteristics were similar to the larger cohort. Our results were potentially subject to selection bias, which could inflate the positive responses about decision quality and decisional conflict. However, the knowledge deficits are likely to be valid and suggest a need to better inform eligible veterans about the benefits and harms of screening. We did not have sufficient follow-up time to determine whether veterans were adherent to annual screenings. We showed that almost all those with abnormal imaging results completed diagnostic evaluations and/or were evaluated by pulmonary. As the program matures, we will be able to track outcomes related to cancer diagnoses and treatment.
Conclusions
A centralized LCS program was able to deliver SDM and enroll veterans in a screening program. While veterans were confident in their decision to screen and felt that they participated in decision making, knowledge testing indicated important deficits. Furthermore, we observed that many veterans did not meaningfully engage in SDM. Clinicians will need to frame the decision as patient centered at the time of referral, highlight the role of the NPC and importance of SDM, and be able to provide adequate decision support. The SDM visits can be enhanced by ensuring that veterans are able to review decision aids. Telemedicine is an acceptable and effective approach for supporting screening discussions, particularly for rural veterans.26
Acknowledgments
The authors thank the following individuals for their contributions to the study: John Paul Hornbeck, program support specialist; Kelly Miell, PhD; Bradley Mecham, PhD; Christopher C. Richards, MA; Bailey Noble, NP; Rebecca Barnhart, program analyst.
