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Original Research |

Evaluations of Implementation at Early-adopting Lung Cancer Screening Programs: Lessons Learned

Yaron B. Gesthalter, MD; Elisa Koppelman, MSW, MPH; Rendelle Bolton, MSW, MA; Christopher G. Slatore, MD, MS; Sue H. Yoon, MSN, NP-C; Hilary C. Cain, MD; Nichole T. Tanner, MD, MSCR; David H. Au, MD, MS; Jack A. Clark, PhD; Renda Soylemez Wiener, MD, MPH
Author and Funding Information

Author contributions: Dr. Wiener had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Au, Clark, Slatore, Wiener. Acquisition of data: Bolton, Clark, Koppelman, Wiener. Analysis and interpretation of data: Bolton, Clark, Koppelman, Wiener. Drafting of the manuscript: Gesthalter, Wiener. Critical revision of the manuscript for important intellectual content: Au, Bolton, Cain, Clark, Gesthalter, Koppelman, Slatore, Tanner, Wiener, Yoon. Obtained funding: Au, Clark, Slatore, Wiener. Study supervision: Clark, Wiener

The authors have no conflicts of interest. This study was funded by the VA QUERI RRP 12-533. An earlier version of this work was presented at the American Thoracic Society International Conference, May 2016, San Francisco, CA.

1The Pulmonary Center, Boston University School of Medicine, Boston, MA

2Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA

3Boston University School of Public Health, Boston, MA

4Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR

5Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University, Portland, OR

6Pulmonary Section, VA Boston HealthCare System, Boston, MA

7VA Connecticut Healthcare System, West Haven, CT

8Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT

9Health Equity and Rural Outreach Innovation Center, RHJ VA Hospital, Charleston, SC

10Department of Medicine, Division of Pulmonary Critical Care, Medical University of South Carolina, Charleston, SC

11Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA

12Division of Pulmonary Critical Care Medicine, University of Washington, Seattle, WA

Corresponding Author: Renda Soylemez Wiener, MD, MPH, Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, 200 Springs Road, Bldg 70 (152), Bedford, MA 01730.


Copyright 2017, . All Rights Reserved.


Chest. 2017. doi:10.1016/j.chest.2017.02.012
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Abstract

Background  Guidelines recommend lung cancer screening 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 lung cancer screening 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 lung cancer screening implementation at three Veterans Health Administration facilities, conducting semi-structured 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 lung cancer screening, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of screen-detected pulmonary nodules and difficulty obtaining primary care buy-in. To manage workload, programs employed 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 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 intra-disciplinary communication.

Conclusion  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 lung cancer screening programs.


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