Implementing Shared Decision-Making for Cancer Screening in Primary Care

在初级保健中实施癌症筛查的共同决策

• 批准号: 10295037
• 负责人: TANNER J CAVERLY
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-04-01 至 2023-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10295037
• 关键词: Address; Clinic Visits; Clinical; Collaborations; Communication; Data; Decision Making; Decision Support Systems; Educational Intervention; Ensure; Equilibrium; Evaluation; Exposure to; Face; Foundations; Funding; Goals; Guidelines; Health; Heterogeneity; Individual; Intervention; Interview; Lead; Left; Length; Malignant neoplasm of lung; Mentors; Methods; Modeling; Monitor; Morbidity - disease rate; Outpatients; Paper; Patient Preferences; Patients; Policy Maker; Preparation; Preventive care; Preventive service; Primary Health Care; Procedures; Process; Published Comment; Qualitative Methods; Recommendation; Research; Research Personnel; Resources; Risk; Risk Estimate; Sampling; Screening for cancer; Services; Stream; Survey Methodology; Surveys; Testing; Time; Training; Translating; Uncertainty; Veterans; Visit; Work; base; care providers; clinical encounter; clinical practice; communication theory; design; early experience; feasibility testing; flexibility; implementation barriers; improved; individual patient; innovation; low dose computed tomography; lung cancer screening; member; mortality; novel; patient engagement; personalized approach; personalized screening; preference; primary care services; primary care setting; programs; prototype; recruit; satisfaction; screening; screening services; shared decision making; skills; tool; tv watching; usability; wiki

Even more than other screening services, it is difficult to know which patients are most likely to benefit from lung cancer screening (LCS). More difficult yet is explaining to patients the trade-offs of screening for them personally, particularly when time for discussing preventive services is limited to less than 5 minutes during a busy visit. Decision support can help, but must contain 3 key features to be maximally effective and sustainable: 1) communication of accurate estimates of the benefit of LCS for an individual patient; 2) design and content that incorporates the values and concerns of informed stakeholders (clinicians, VA leaders, and Veterans) and a practical approach to routinely personalizing screening during busy clinic visits; and 3) design that optimizes the tool’s fit with VA clinical workflows. In collaboration with my mentors and steering committee, I propose to carry out work that will leverage and substantially build on a project I am co-leading – Ann Arbor VA’s funded PROVE QUERI – which studies expeditious implementation of a more traditional shared decision- making (SDM) tool equipped with only the first feature (individualized estimates of LCS benefit). To achieve these goals the CDA has 3 aims. Aim 1 – Assess informed stakeholder views (3 projects): In this aim I will use democratic deliberation to extensively inform and engage key LCS stakeholders to understand their opinions/recommendations about offering and discussing LCS. In project 1a (“Clinical Forum”) I will recruit a group of 12-15 clinical stakeholders (PCPs, screening coordinators, and clinical leaders) from VA nationwide to inform them of the heterogeneity of LCS benefit and engage them in deliberation, obtaining their recommendations for “simple boundary rules” for when screening should be encouraged, discouraged, or left wholly to l patient choice. In project 1b (2 “Veteran Forums”) I will recruit a random sample of up to 64 VISN 10 Veterans who are LCS-eligible and conduct 2 separate daylong forums. The core objective will be to utilize 2 content experts with differing viewpoints to inform Veterans about the challenges of LCS implementation and the constraints of clinical practice, and then to obtain individual and group recommendations for “simple how-to rules” clinicians can use to involve patients in LCS discussions given the competing demands PCPs face. In project 1c I will use risk communication theory to develop innovative new tool features that incorporate the VA Stakeholder guidance and can help guide clinicians in how to efficiently personalize LCS. Aim 2 – Optimize decision support ‘fit’ with the VA clinical context (2 projects): In project 2a I will conduct a synthesis analysis of multiple streams of PROVE QUERI data to understand how LCS decision support can be redesigned to overcome implementation challenges and enhance motivators for tool use. Then, in project 2b I explore wiki surveys as a new method of engaging clinical stakeholders to: 1) evaluate the new decision support content and design strategies generated in projects 1c/2a; 2) contribute new ideas; and 3) help prioritize which strategies and content for inclusion in the upgraded tool. Aim 3 – Pilot (3 projects): Informed by Aims 1 and 2, I will develop a paper-based prototype in project 3a. Then, in project 3b I will assess usability by conducting 5-8 monitored mock clinical encounters (each mock encounter will include a patient, a PCP, and a PACT staff member). In project 3c, I will pilot the tool with 30 PCPs who are purposively sampled from 6 diverse outpatient VA settings. Each PCP will first receive a 1-on-1 educational intervention. I will then test the feasibility of using my paper-based decision support with 2-3 LCS- eligible Veterans per participating PCP. Encounters will be audio recorded to assess the content and length of LCS discussions. PCPs and patients will complete surveys and interviews to assess satisfaction and comfort with the LCS decision-making process. The core goal is to assess whether the tool can support brief and high- quality personalized LCS discussions while being acceptable to a diverse sample of PCPs and Veterans.

甚至比其他筛查服务更难知道哪些患者最有可能受益 肺癌筛查（LCS）更困难的是向患者解释筛查的利弊， 特别是当讨论预防服务的时间限制在5分钟以内时， 在一次忙碌访问中。决策支持可以提供帮助，但必须包含3个关键功能才能最大限度地发挥作用， 可持续性：1）传达LCS对个体患者获益的准确估计; 2）设计 以及包含知情利益相关者（临床医生、VA领导和 退伍军人）和一个实用的方法，在忙碌的诊所访问定期个性化筛选;和3）设计 优化了该工具与VA临床工作流程的匹配。在我的导师和指导委员会的合作下， 我提议开展的工作将充分利用和充分建立在我共同领导的一个项目上--安阿伯 弗吉尼亚州资助的PROVE QUERI -研究更传统的共同决策的快速实施- 这是一种仅配备第一特征（LCS效益的个体化估计）的SDM工具。实现 CDA有三个目标。 目标1 -评估知情的利益相关者的意见（3个项目）：在这个目标中，我将使用民主审议 广泛告知和参与LCS的主要利益相关者，以了解他们的意见/建议， 提供和讨论LCS。在项目1a（“临床论坛”）中，我将招募12-15名临床利益相关者 (PCPs筛选协调员和临床负责人），以告知他们 LCS受益并参与审议，获得他们对“简单边界规则”的建议， 什么时候应该鼓励、不鼓励或完全由患者选择进行筛查。在项目1b（2“退伍军人 论坛”）我将招募一个随机样本多达64 VISN 10退伍军人谁是LCS资格和进行2 单独的一天论坛。核心目标是利用2名观点不同的内容专家， 告知退伍军人LCS实施的挑战和临床实践的限制，然后 为了获得个人和团体的“简单操作规则”建议，临床医生可以使用这些规则来让患者参与进来， 考虑到PCP面临的竞争性需求，LCS讨论中存在一些问题。在项目1c中，我将使用风险沟通理论 开发创新的新工具功能，这些功能包含VA利益相关者指南， 临床医生如何有效地个性化LCS。 目标2 -优化决策支持与VA临床背景的“匹配”（2个项目）：在项目2a中，我将 对PROVE QUERI数据的多个流进行综合分析，以了解LCS决策 可以重新设计支助，以克服执行方面的挑战，并增强使用工具的动力。然后，我 在项目2b中，我探索了wiki调查作为一种新的方法，使临床利益相关者参与：1）评估新的 在项目1c/2a中产生的决策支持内容和设计战略; 2）提出新的想法; 3） 帮助确定哪些战略和内容优先纳入升级后的工具。 目标3 -试点（3个项目）：根据目标1和2，我将在项目3a中开发纸质原型。 然后，在项目3b中，我将通过进行5-8次监测模拟临床接触（每次模拟）来评估可用性 接触将包括患者、PCP和PACT工作人员）。在项目3c中，我将使用30个 从6个不同的门诊VA设置有目的地抽样的PCP。每个PCP将首先接受一对一的 教育干预。然后，我将测试使用我的基于纸张的决策支持与2-3 LCS的可行性- 每个参与PCP的合格退伍军人。会议将被录音，以评估会议的内容和长度。 LCS讨论。PCP和患者将完成调查和访谈，以评估满意度和舒适度 LCS的决策过程。核心目标是评估该工具是否能够支持简短和高- 高质量的个性化LCS讨论，同时为PCP和退伍军人的不同样本所接受。