Factors Associated With Declining Lung Cancer Screening After Discussion With a Physician in a Cohort of US Veterans.
Factors Associated With Declining Lung Cancer Screening After Discussion With a Physician in a Cohort of US Veterans.
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DOI：
10.1001/jamanetworkopen.2022.27126
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发表时间：
2022-08-01
影响因子：
13.8
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这项队列研究调查了符合肺癌筛查条件的美国退伍军人接受或拒绝肺癌筛查的频率，以及与他们的决定相关的患者和设施水平因素。哪些因素与退伍军人肺癌筛查（LCS）下降有关？在这项队列研究中，43257名美国退伍军人提供LCS，32%的人拒绝;年龄较大或合并症较严重的退伍军人更有可能拒绝筛查，而黑人和西班牙裔退伍军人更有可能接受它。研究结果表明，改善患者和医生之间的LCS讨论可以加强以患者为中心的护理，并解决LCS中的差异。肺癌筛查（LCS）在美国未得到充分利用，特别是在服务不足的人群中，并且对与LCS下降相关的因素知之甚少。当提供LCS时，指南要求共同决策，以确保知情的、以患者为中心的决策。评估退伍军人LCS下降的频率，并检查与LCS下降相关的因素。这项回顾性队列研究包括符合LCS条件的美国退伍军人，他们在2013年1月1日至2021年2月1日期间由30家退伍军人健康管理局（VHA）设施中的1家的医生提供LCS，这些设施常规使用电子健康记录临床提醒记录LCS资格和退伍军人接受或拒绝LCS的决定。数据来自退伍军人事务部（VA）企业数据仓库或VA信息资源中心的医疗保险索赔文件。主要结果是记录，在临床提醒，退伍军人拒绝LCS后，与医生讨论。将医生和医疗机构作为随机效应进行逻辑回归分析，以评估与同意LCS相比，与LCS下降相关的因素。在43257名符合LCS条件的退伍军人中（平均[SD]年龄，64.7 [5.8]岁），95.9%为男性，84.2%为白色，37.1%居住在农村邮政编码; 32.0%拒绝筛查。如果退伍军人更年轻，他们不太可能拒绝LCS（年龄55-59岁：比值比[OR]，0.69; 95% CI，0.64-0.74;年龄60-64岁：OR，0.80; 95% CI，0.75-0.85），黑人（OR，0.80; 95%CI，0.73-0.87），为西班牙裔（OR，0.62; 95% CI，0.49-0.78），无需支付共付金（OR，0.92; 95% CI，0.85-0.99），或更频繁地使用VHA医疗保健（门诊：OR，0.70; 95% CI，0.67-0.72;急诊：OR，0.86; 95% CI，0.80-0.92）。退伍军人更有可能下降LCS，如果他们年龄较大（年龄70-74岁：OR，1.27; 95% CI，1.19-1.37;年龄75-80岁：OR，1.93; 95% CI，1.73-2.17），居住地远离VHA筛查机构（OR，1.06; 95% CI，1.03-1.08），长期护理天数更多（OR，1.13; 95% CI，1.07-1.19），具有较高的Elixhauser Comorbid指数评分（OR，1.04; 95% CI，1.03-1.05），或有特定的心血管或精神健康状况（充血性心力衰竭：OR，1.25; 95% CI，1.12-1.39;中风：OR，1.14; 95% CI，1.01-1.28;精神分裂症：OR，1.87; 95% CI，1.60-2.19）。提供LCS的医生和机构分别占LCS下降的19%和36%。在这项队列研究中，患有严重合并症的老年退伍军人更有可能拒绝LCS，黑人和西班牙裔退伍军人更有可能接受它。LCS决策的变化更多地由提供LCS的设施和医生而不是患者因素来解释。这些研究结果表明，共享决策对话中，患者在指导护理中发挥核心作用，可能会加强以患者为中心的护理，并解决LCS的差异。
This cohort study investigates the frequency with which US veterans eligible for lung cancer screening accept or decline it and the patient- and facility-level factors associated with their decision. What factors are associated with veterans declining lung cancer screening (LCS)? In this cohort study of 43 257 US veterans offered LCS, 32% declined; veterans who were older or had more severe comorbidity were more likely to decline screening, whereas Black and Hispanic veterans were more likely to accept it. The facility and physician offering LCS accounted for more variation in decisions than did patient factors. The findings suggest that improving LCS discussions between patients and physicians could enhance patient-centered care and address disparities in LCS. Lung cancer screening (LCS) is underused in the US, particularly in underserved populations, and little is known about factors associated with declining LCS. Guidelines call for shared decision-making when LCS is offered to ensure informed, patient-centered decisions. To assess how frequently veterans decline LCS and examine factors associated with declining LCS. This retrospective cohort study included LCS-eligible US veterans who were offered LCS between January 1, 2013, and February 1, 2021, by a physician at 1 of 30 Veterans Health Administration (VHA) facilities that routinely used electronic health record clinical reminders documenting LCS eligibility and veterans’ decisions to accept or decline LCS. Data were obtained from the Veterans Affairs (VA) Corporate Data Warehouse or Medicare claims files from the VA Information Resource Center. The main outcome was documentation, in clinical reminders, that veterans declined LCS after a discussion with a physician. Logistic regression analyses with physicians and facilities as random effects were used to assess factors associated with declining LCS compared with agreeing to LCS. Of 43 257 LCS-eligible veterans who were offered LCS (mean [SD] age, 64.7 [5.8] years), 95.9% were male, 84.2% were White, and 37.1% lived in a rural zip code; 32.0% declined screening. Veterans were less likely to decline LCS if they were younger (age 55-59 years: odds ratio [OR], 0.69; 95% CI, 0.64-0.74; age 60-64 years: OR, 0.80; 95% CI, 0.75-0.85), were Black (OR, 0.80; 95% CI, 0.73-0.87), were Hispanic (OR, 0.62; 95% CI, 0.49-0.78), did not have to make co-payments (OR, 0.92; 95% CI, 0.85-0.99), or had more frequent VHA health care utilization (outpatient: OR, 0.70; 95% CI, 0.67-0.72; emergency department: OR, 0.86; 95% CI, 0.80-0.92). Veterans were more likely to decline LCS if they were older (age 70-74 years: OR, 1.27; 95% CI, 1.19-1.37; age 75-80 years: OR, 1.93; 95% CI, 1.73-2.17), lived farther from a VHA screening facility (OR, 1.06; 95% CI, 1.03-1.08), had spent more days in long-term care (OR, 1.13; 95% CI, 1.07-1.19), had a higher Elixhauser Comorbidity Index score (OR, 1.04; 95% CI, 1.03-1.05), or had specific cardiovascular or mental health conditions (congestive heart failure: OR, 1.25; 95% CI, 1.12-1.39; stroke: OR, 1.14; 95% CI, 1.01-1.28; schizophrenia: OR, 1.87; 95% CI, 1.60-2.19). The physician and facility offering LCS accounted for 19% and 36% of the variation in declining LCS, respectively. In this cohort study, older veterans with serious comorbidities were more likely to decline LCS and Black and Hispanic veterans were more likely to accept it. Variation in LCS decisions was accounted for more by the facility and physician offering LCS than by patient factors. These findings suggest that shared decision-making conversations in which patients play a central role in guiding care may enhance patient-centered care and address disparities in LCS.