Table 3 Concordance and discordance of perspectives on Lung Cancer Screening (LCS)a by Role: Practice Member (Clinicians, Clinical Staff, Administrators) and patient in rural primary care using RE-AIM Dimensions
RE-AIM Dimension: Reach | |
Concordance of perspectives across roles | Insurance – Consistent issue of insurance coverage as a perceived barrier to patients completing LCS • Lack of private insurance coverage and also meeting the deductible are problems • Patients can’t or don’t want to pay for it when not covered |
Hassle – consistent views of hassles involved • For patients the time, distance, doing the driving and navigating, not wanting to miss work • For practice members the time and rigmarole involved in coordinating, getting reimbursed | |
Patient resistance – consistent discussion of patient reasons for declining • Some patients have fatalistic view and are not amenable to screening; some fear and do not want to know the results; some think “it’s none of my doc’s business”, some disregard the known risks; some are amendable to screening | |
Discordance of perspectives across roles | Consistency of offering the screening – variable across groups on how often LCS is offered • Patients variable about recalling being offered or not offered LCS • Across roles and practices, variability in offering LCS from not at all, to always when eligible to occasionally |
RE-AIM Dimension: Effectiveness | |
Concordance of perspectives across roles | Smoking cessation versus LCS – More of the discussion about effectiveness was in the smoking cessation realm rather than LCS specifically • A few patients described the smoking cessation counseling conversation as effective with helping them quit; the provision of smoking cessation methods was helpful: (Chantix, Colorado quit line) or the way clinicians approached the conversation (“floated in the back of my mind”; doctors telling them straight forward that if they did not quit they would die) Relevance – Across groups, not many people knew patients with LC and less able to describe its effectiveness |
Discordance of perspectives across roles | Importance – • Discordant views about screening from staff/clinicians as opposed to patients – all clinicians staff thought it important and most thought it as important as other screenings, whereas only some patients felt this way |
RE-AIM Dimension: Adoption | |
Concordance of perspectives across roles | Smoking cessation – • Procedures for asking about and offering smoking cessation were consistently offered as reported by all groups • Patients receive smoking cessation counseling and methods from their doctors. The only instance where this did not occur was the patient withheld his/her smoking history from the doctor or had quit prior to joining the practice |
Knowledge about LCS – • Consistent across roles describing the variability with clinician knowledge of LCS and use of CT vs. LDCT vs. chest x-rays; variable knowledge about radiation concern with every year testing; one clinician not familiar with guidelines at all | |
Workflow for LCS – • Systems set up to make it easier (like EMR prompts, tickler, etc.) are a factor, variable use in practice • Some patients had been told about LCS and received the screening. Some refused the screening. Most patients that had not been told about LCS, and most of these patients were interested in learning more | |
Patient factors influence clinician and team willingness to do this (burden for benefit equation) • Practice members relay that patients push back due to lacking insurance coverage, hassles and other resistance which makes clinicians less likely to want to offer it | |
Discordance of perspectives across roles | Workflow for LCS – • Clinicians most informed about why they are or are not doing this because it is falls within their role, other roles not as clear what happens with the clinician Patients had less to say about influences on adoption but were able to report whether they had been offered these things or not |
RE-AIM Dimension: Implementation | |
Concordance of perspectives across roles | Smoking assessment and cessation assistance – • Practice members discuss consistency of providing and how it works well, the need to be sensitive and respect patient decision • Patients described that doctors should bring up smoking cessation with patients, encouraging patients to quit but not “pushing it.” |
Communication – • Practice members communicating without being condescending with patients echoing similar sentiments | |
Knowledge about shared decision making with LCS – • Most clinicians are not doing shared decision making as they describe it (say they are but are not by description); some gaps for some in knowing about this mandate and other guidelines for LCS • Some practices: shared decision making is employed to get the patient to “say yes”; some patients confused about being billed for telehealth since not in the office | |
LCS Work flows – • LCS doesn’t get done as much as other screenings because there are more guidelines and criteria to figure out as well as steps to do; unique from other screenings • Lack of time is a factor (many other issues, not getting paid when patient not there) • Telehealth has made figuring out patient issues easier; portal helps communication for smoking cessation; Follow-up on smoking cessation lacking – one-time conversation; inconsistency of recommendation by clinician for smoking cessation (training might help); having a regular MA/Dr pairing may facilitate more efficiency (patient doesn’t have to repeat the spiel); LCS being done with wellness visit or other types of visits | |
Discordance of perspectives across roles | LCS Work flows – • Clinicians and staff much more on how to make it happen consistently and well in the practice • Patients who had it done reported being asked and having follow-up and recommendations |
Quality metrics/reporting—quality report does not have LCS on it right now; there are quality metrics for many screenings—is there for this? | |
RE-AIM Dimension: Maintenance | |
Discordance of perspectives across roles | Maintenance was covered less as a topic than other RE-AIM dimensions overall |
At the patient level—was considered important for some patients to continue to stay quit and get LCS as recommended; others not so much for reasons covered in other categories | |
At the practice level—Clinicians recognize the need to do annual screening but there are implementation issues with doing so • Hard to recommend annually (concern for radiation risk to patients) and just plain remembering to do it again and where patient is in the process | |