Multilevel Interventions to Increase Adherence to Lung Cancer Screening

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ABSTRACT Screening for lung cancer has the potential for a profound public health benefit. Lung cancer is the leading cause of US cancer morbidity and mortality for both men and women, responsible for more deaths than breast, cervical, colorectal, and prostate cancers combined. Annual screening with low-dose computed tomography (LDCT) reduced lung cancer mortality by 20%. Successful population-based screening requires continuous monitoring to adherence repeat screening in high risk adults to achieve similar results. Repeat annual screening is necessary for early detection of lung cancer. Baseline or first LDCT scans detect prevalent lung cancer, when subsequent screening detects new nodules. However, adherence to screening is low, ranging at 28-38% from centers nationally. Multilevel interventions, which target patients, clinicians, and healthcare systems, offer a promising framework to address the gaps in lung cancer screening to achieve guideline- recommended lung cancer screening. Our mixed-methods pilot study with KPWA stakeholders two critical components to improve adherence to repeat screening: providing education for patients on lung cancer screening, and offering reminders for on-time return to screening. We developed two novel patient-centered interventions using principles of human-centered design to address these needs: 1) Patient Voices Video that incorporates patient testimonials to acknowledge receipt of screening, a tailored reminder of time due for next scan, and reassurance to reduce fear of screening and role of loved ones to support health choices; and 2) Stepped Reminders, that directly reminds patients when their next scan is due. Both interventions are facilitated by a health system electronic health record (EHR) build to track patients for population health management and a clinically-embedded medical assistant to deliver interventions. The goal of this proposal is to test these two interventions relative to usual care to promote adherence to repeat screening in a pragmatic cluster randomized trial enrolling 1775 adult KPWA members, who complete a screening LDCT in 2022-2025 across 34 KPWA primary care clinics in a 2x2 factorial-designed study. Study arms include: a) Stepped Reminders alone; b) Patient Voices Video alone; c) both interventions; or d) usual care. To address our goals, our specific aims are to: 1) Compare effectiveness of two multilevel interventions relative to usual care in improving (a) rates of adherence to lung cancer screening, (b) patient-centered outcomes; and (c) clinic outcomes; and 2) Determine the patient-, clinician-, and system-level factors that influence changes in adherence to inform lung cancer screening programs. To date, no randomized clinical trial has evaluated strategies to improve adherence to lung cancer screening in US populations with multilevel strategies. We will move the field forward by providing effective, scalable interventions to improve lung cancer screening adherence to achieve the population-based mortality benefits promised by large clinical trials that motivated screening guidelines.