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.
Background: Veterans suffer substantial morbidity and mortality from lung cancer. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce mortality. Guidelines recommend counseling and shared decision-making (SDM) to address the benefits and harms of screening and the importance of tobacco cessation before patients undergo screening.
Observations: We implemented a centralized LCS program at the Iowa City Veterans Affairs Medical Center with a nurse program coordinator (NPC)–led telephone visit. Our multidisciplinary team ensured that veterans referred from primary care met eligibility criteria, that LDCT results were correctly coded by radiology, and that pulmonary promptly evaluated abnormal LDCT. The NPC mailed a decision aid to the veteran and scheduled a SDM telephone visit. We surveyed veterans after the visit using validated measures to assess knowledge, decisional conflict, and quality of decision making. We conducted 105 SDM visits, and 91 veterans agreed to LDCT. Overall, 84% of veterans reported no decisional conflict, and 59% reported high-quality decision making. While most veterans correctly answered questions about the harms of radiation, false-positive results, and overdiagnosis, few knew when to stop screening, and most overestimated the benefit of screening and the predictive value of an abnormal scan. Tobacco cessation interventions were offered to 72 currently smoking veterans.
Conclusions: We successfully implemented an LCS program that provides SDM and tobacco cessation support using a centralized telehealth model. While veterans were confident about screening decisions, knowledge testing indicated important deficits, and many did not engage meaningfully in SDM. Clinicians should frame the decision as patient centered at the time of referral, highlight the importance of SDM, and be able to provide adequate decision support.
Lung cancer is the second most frequently diagnosed cancer among US veterans and the leading cause of cancer death.1 Clinical trials have shown that annual screening of high-risk persons with low-dose computed tomography (LDCT) can reduce the risk of dying of lung cancer.2 In 2011, the National Lung Screening Trial (NLST) reported that over a 3-year period, annual LDCT screening reduced the risk of dying of lung cancer by 20% compared with chest radiograph screening.3 Lung cancer screening (LCS), however, was associated with harms, including false-positive results, complications from invasive diagnostic procedures, incidental findings, overdiagnosis, and radiation exposure.
The US Preventive Services Task Force (USPSTF) began recommending annual screening of high-risk persons after publication of the NLST results.4 The Veterans Health Administration (VHA) recommended implementing LCS in 2017.5 Guidelines, however, have consistently highlighted the complexity of the decision and the importance of engaging patients in thorough discussions about the potential benefits and harms of screening (shared decision making [SDM]). The Centers for Medicare and Medicaid Services (CMS) has issued coverage determinations mandating that eligible patients undergo a counseling visit that uses a decision aid to support SDM for LCS and addresses tobacco use.6,7 However, primary care practitioners (PCPs) face many challenges in delivering SDM, including a lack of awareness of clinical trial results and screening guidelines, competing clinical demands, being untrained in SDM, and not having educational resources.8 Patients in rural locations face travel burdens in attending counseling visits.9
We conducted a pilot study to address concerns with delivering SDM for LCS to veterans. We implemented a centralized screening model in which veterans were referred by clinicians to a trained decision coach who conducted telephone visits to discuss the initial LCS decision, addressed tobacco cessation, and placed LDCT orders. We evaluated the outcomes of this telemedicine visit by using decision quality metrics and tracking LCS uptake, referrals for tobacco cessation, and clinical outcomes. The University of Iowa Institutional Review Boardconsidered this study to be a quality improvement project and waived informed consent and HIPAA (Health Insurance Portability and Accountability Act) authorization requirements.
