Evaluating Centralizing Interventions to Address Low Adherence to Lung Cancer Screening Follow-up in Decentralized Settings

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PROJECT SUMMARY/ABSTRACT Lung cancer is the leading cause of cancer death in the United States, and lung cancer screening has been demonstrated to effectively reduce lung cancer by 20-26% in eligible patients. Despite 10 years of recommendations endorsing screening, evidence suggests that real-world implementation of screening along the care continuum has been poor. Specifically, prior work reveals that adherence to routine annual screening and specialized follow-up after positive lung cancer screening exams is suboptimal, with a median adherence of 40-60% across clinical programs. Follow-up after either negative or positive lung cancer screening is a critical target to achieve mortality benefits seen in clinical trials, as adherence to follow-up was >90% in these studies, and more than half of all screen-detected lung cancers were diagnosed in follow-up. Prior studies of adherence to follow-up been largely observational, single center and performed in academic settings, but have demonstrated that clinical lung cancer screening programs which contain centralized program-level interventions such as care coordination have two-to-three times the rate of follow-up adherence compared to programs where lung cancer screening is largely managed by primary providers. Prior observational work also suggests centralized programmatic interventions may mitigate health disparities in lung cancer screening. It is therefore critical to prospectively evaluate feasible and effective centralized program interventions in community settings to translate the benefits to screening programs and patients. To fill this important knowledge gap, the central objective of this study is to generate evidence of barriers and facilitators to lung cancer screening follow-up in decentralized community programs, adapt and introduce centralizing interventions in these settings and rigorously measure the effectiveness and implementation of these interventions. This objective will be met by achievement of three specific aims performed at 3 non- academic regional partnering sites with large rural and Hispanic populations. In the first aim, we will determine system-, provider- and patient-level facilitators to LCS follow-up in these settings using an innovative rapid ethnographic approach supplemented by semi-structure interviews. In the second aim, we will adapt and evaluate centralizing interventions including defined care pathways and after-screening care coordination measuring the impact on adherence and socioeconomic, rural-urban and racial-ethnic disparities. Finally in the third aim, we will evaluate the implementation of these strategies with a key focus on the tension between fidelity and adaptations as these interventions mature. The aims will be grounded in an integration of the Consolidative Framework of Implementation Research, RE-AIM and a NIH-developed health disparities framework. Our team has extensive experience in lung cancer screening implementation and disparities with expertise in adapting and evaluating pragmatic interventions in community settings. This project will generate essential knowledge to improve lung cancer screening follow-up in real-world clinical programs.