Implementation of a Web-Based Tool for Shared Decision-making in Lung Cancer Screening: Mixed Methods Quality Improvement Evaluation.
Implementation of a Web-Based Tool for Shared Decision-making in Lung Cancer Screening: Mixed Methods Quality Improvement Evaluation.
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肺癌风险和预期寿命在符合低剂量计算机断层扫描肺癌筛查（LCS）的患者之间差异很大，这对优化不同患者的LCS决策具有重要意义。为了在决策过程中考虑这种异质性，需要基于Web的决策支持工具来实现快速计算并简化获取个性化信息的过程，从而更准确地告知患者-临床医生LCS讨论。我们创建了DecisionPrecision，一个面向临床医生的基于网络的决策支持工具，以帮助定制LCS讨论，以适应患者的个性化肺癌风险和估计的净收益。我们的研究的目的是测试两种策略，在初级保健实施决策精度在八个退伍军人事务部医疗中心：质量改进（QI）的培训方法和学术细化（AD）。第1阶段包括一项多中心、集群随机试验，比较标准实施的有效性（在电子健康记录中添加DecisionPrecision链接，与标准实施以及学习、参与、行动和过程[LEAP] QI培训计划）。主要结果指标是LEAP QI培训前后每个站点的DecisionPrecision使用情况。研究的第二阶段检查了AD作为DecisionPrecision在所有8个医疗中心的实施策略的潜在有效性。通过比较AD访视前后的绝对工具使用情况，并在AD访视后与一部分初级保健医生（PCP）进行半结构化访谈，对结局进行评估。第一阶段的研究结果显示，参与LEAP QI培训项目的研究中心使用DecisionPrecision的频率显著高于标准实施研究中心（在6个月内，LEAP研究中心平均使用工具190.3，SD 174.8次，而标准研究中心平均使用工具3.5，SD 3.7次; P<0.001）。然而，这一发现被标准实施地点缺乏筛查协调员所混淆。在第2阶段，AD前后6个月的工具使用没有差异（95% CI-5.06至6.40; P= 0.82）。与PCP的后续访谈表明，AD战略提高了供应商对该工具好处的认识和赞赏。然而，其他优先事项和有限的时间阻止了PCP在常规临床访视期间使用它们。第1阶段的研究结果并没有提供结论性的证据，证明QI培训方法对在PCP中实施LCS决策支持工具的益处。此外，2期研究结果显示，我们的轻触式单次访视AD策略并未增加工具使用。为了使PCP能够使用工具，基于预测的工具必须完全自动化并集成到电子健康记录中，从而帮助提供者在众多竞争需求中个性化LCS讨论。PCP还需要更多的时间与患者进行共同决策讨论。ClinicalTrials.gov NCT02765412; https://clinicaltrials.gov/ct2/show/NCT02765412
Lung cancer risk and life expectancy vary substantially across patients eligible for low-dose computed tomography lung cancer screening (LCS), which has important consequences for optimizing LCS decisions for different patients. To account for this heterogeneity during decision-making, web-based decision support tools are needed to enable quick calculations and streamline the process of obtaining individualized information that more accurately informs patient-clinician LCS discussions. We created DecisionPrecision, a clinician-facing web-based decision support tool, to help tailor the LCS discussion to a patient’s individualized lung cancer risk and estimated net benefit. The objective of our study is to test two strategies for implementing DecisionPrecision in primary care at eight Veterans Affairs medical centers: a quality improvement (QI) training approach and academic detailing (AD). Phase 1 comprised a multisite, cluster randomized trial comparing the effectiveness of standard implementation (adding a link to DecisionPrecision in the electronic health record vs standard implementation plus the Learn, Engage, Act, and Process [LEAP] QI training program). The primary outcome measure was the use of DecisionPrecision at each site before versus after LEAP QI training. The second phase of the study examined the potential effectiveness of AD as an implementation strategy for DecisionPrecision at all 8 medical centers. Outcomes were assessed by comparing absolute tool use before and after AD visits and conducting semistructured interviews with a subset of primary care physicians (PCPs) following the AD visits. Phase 1 findings showed that sites that participated in the LEAP QI training program used DecisionPrecision significantly more often than the standard implementation sites (tool used 190.3, SD 174.8 times on average over 6 months at LEAP sites vs 3.5 SD 3.7 at standard sites; P<.001). However, this finding was confounded by the lack of screening coordinators at standard implementation sites. In phase 2, there was no difference in the 6-month tool use between before and after AD (95% CI −5.06 to 6.40; P=.82). Follow-up interviews with PCPs indicated that the AD strategy increased provider awareness and appreciation for the benefits of the tool. However, other priorities and limited time prevented PCPs from using them during routine clinical visits. The phase 1 findings did not provide conclusive evidence of the benefit of a QI training approach for implementing a decision support tool for LCS among PCPs. In addition, phase 2 findings showed that our light-touch, single-visit AD strategy did not increase tool use. To enable tool use by PCPs, prediction-based tools must be fully automated and integrated into electronic health records, thereby helping providers personalize LCS discussions among their many competing demands. PCPs also need more time to engage in shared decision-making discussions with their patients. ClinicalTrials.gov NCT02765412; https://clinicaltrials.gov/ct2/show/NCT02765412