Article Figures & Data
Figures
- Figure 1.
Map of key participant locations.
Tables
Key Constructs Definition Domain: Inner Setting
Construct: Implementation ClimateA climate within health care to improve and encourage lung cancer screening. Participants noted the importance and value of lung cancer screening implementation and utilization. To prompt lung cancer screening, it would be helpful to create structured workflow processes, like electronic health record (EHR) reminders, to identify eligible patients. Domain: Inner Setting
Construct: Networks & CommunicationsFormal or informal connections between individuals, units, services, and hierarchies. The use of decision aids to guide decision-making conversations with patients could improve engagement with LCS, particularly in populations with lower health literacy, but there are barriers to use. Domain: Outer Setting
Construct: Patient Needs, Resources, & BarriersBarriers that are outside of the Health Care System control, usually to do with geographical distance, level of education of patients, economical or financial situation of patients. Many PCPs perceived the geographic location of the low-dose CT as the biggest barrier. Many patients also do not have access to personal transportation, and others have a distrust of big cities and hospitals. Domain: Implementation Process
Construct: ChampionsA team member who takes the role of champion and spearheads a program within a clinic to motivate and encourage the patient population to engage. Participants practicing in clinics without a lung cancer screening champion described an environment where clinic leadership were not visibly supportive of lung cancer screening, opposed to clinics with a champion. Champions were seen as key facilitators of screening implementation and uptake. They were seen as essential to successful lung cancer screening programs. Abbreviations: LCS, lung cancer screening; CT, computed tomography; PCP, primary care providers.
TRAINING (Physician or APP*) RUCA CATEGORY** FEDERAL DESIGNATION*** OWNERSHIP ACCESS TO LOW-DOSE CT Physician 10 Patient Centered Primary Care Home System 31 to 60 minutes Physician 2 Rural Health Clinic (RHC) System 31 to 60 minutes APP 7 RHC System At institution APP 4 Unknown System >1 hour Physician 1 RHC System >1 hour Physician 10 Federally Qualified Health Center Independent At institution Physician 7 RHC Independent At institution APP 7 Unknown System >1 hour APP 10 RHC System <30 minutes APP 7 RHC Independent 31 to 60 minutes Physician 10 RHC System At institution APP 4 RHC System At institution APP 7 RHC System At institution Physician 4 RHC System At institution Physician Unknown RHC Unknown Unknown Abbreviations: APP, advanced practice practitioner; CT, computed tomography.
↵Notes. **RUCA Category, codes classify U.S. census tracts using measures of population density, urbanization, and daily commuting; urban codes: 1-3, large rural codes: 4-6.1, small rural codes: 7-9.2, and isolated codes: 10-10.6.75
***Definitions: Patient Centered Primary Care Home, A model of primary care organization that delivers primary health care.76
Rural Health Clinic, Clinics intended to increase access to primary care for rural communities in underserved areas.77
Federally Qualified Health Center, Centers intended to increase access to primary care in underserved areas or for underserved populations, regardless of rural/urban location.78
Characteristics N (%) Gender Woman 10 (66%) Man 5 (33%) Racial Background White/Caucasian 14 (93%) More than one race 0 (0%) Preferred not to say 1 (7%) Spanish, Hispanic or Latino 0 (0%) Role of Informant Physician 8 (53%) Non-Physician 7 (47%) Clinic Ownership Independent 3 (20%) System affiliated 11 (73%) Unknown 1 (7%) Clinic Federal Designation Rural Health Clinic 11 (73%) Federally Qualified Health Center 1 (7%) Unknown 3 (20%) Lung Cancer Screening Component Lung Cancer Screening Barriers Workflow Process Improvement Facilitators Patient Identification Lack of adequate workflow systems & Patient non-adherence Document tobacco use in the patient’s EHR; Use the EHR as an LCS patient identification tool via a checklist with the United States Preventive Services Taskforce guidelines; Use of a “huddle” sheet fastened to the exam room door to remind PCPs about preventive services with another staff member who could assure it gets completed Referral Lack of adequate workflow systems Champions to help establish processes like thorough communication pathways between PCP referring clinic and radiology facility performing the low-dose CT scan via electronic health records, a shared online database, or scheduled phone calls Screening Lack of adequate workflow systems Use the EHR or a database to track low-dose CT screening orders and missed low-dose CT scan appointments Result Lack of adequate workflow systems Rely on flags in the EHR to follow-up with patients regarding their scan results; use of the “huddle” sheet to remind the PCP to discuss results Patient Follow-up Post Screen Lack of adequate workflow systems (Lack of support from clinic leadership) Use the EHR or other database to track and monitor patients with abnormal screen results, ideally a database that has alerts and reminders embedded to create reports; Designate clinic staff to track and monitor patients post LCS Patient Navigation Transportation, cost, radiation exposure Designate a patient navigator who is a member of the clinic staff to track and monitor all LCS patients from referral to post-screening follow-up, and can assist with patient needs; Use of mobile CT scanners, SDM interactions conducted via telehealth, increasing awareness of federal cancer centers, and round-trip transportation vouchers Shared Decision-Making Tools Health literacy & Impractical decision aids Use shared decision-making tools, such as toolkits, decision aids, or information sheets, and web-based resources or apps Abbreviations: EHR, electronic health record; LCS, lung cancer screening; low-dose CT, low-dose computed tomography.
Note: Italicized portions indicate suggestions from the literature. Non-italicized portions indicate suggestions from our respondents.
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