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

项目总结/摘要 肺癌是美国癌症死亡的主要原因，肺癌筛查一直是 在符合条件的患者中，已证明可有效降低肺癌20-26%。尽管10年来 支持筛查的建议，有证据表明，筛查的实际实施沿着 护理连续性一直很差。具体来说，先前的工作表明，坚持例行的年度筛查 肺癌筛查阳性后的专业随访不理想， 40-60%的临床项目。肺癌筛查阴性或阳性后的随访是一个 在临床试验中观察到的实现死亡率获益的关键目标，因为这些患者的随访依从性>90% 在所有筛查检测到的肺癌中，有一半以上是在随访中诊断出来的。 先前关于随访依从性的研究主要是观察性、单中心和学术性研究。 但已经证明，临床肺癌筛查计划，其中包含集中 项目级干预措施（如护理协调）的随访依从率是项目级干预措施的2 - 3倍 与肺癌筛查主要由主要提供者管理的项目相比。之前 观察性工作还表明，集中的方案干预措施可能会减轻健康差距， 肺癌筛查因此，前瞻性地评估可行和有效的集中管理至关重要。 在社区环境中进行项目干预，以将益处转化为筛查项目和患者。 为了填补这一重要的知识空白，本研究的中心目标是产生障碍的证据 和促进者肺癌筛查后续分散的社区计划，适应和引进 在这些环境中集中干预措施，并严格衡量 这些干预。这一目标将通过在3个非国家实现三个具体目标来实现： 与大量农村和西班牙裔人口的学术区域合作网站。在第一个目标中，我们将确定 系统，提供者和患者层面的促进者在这些环境中使用创新的快速LCS随访 民族志方法辅以半结构访谈。在第二个目标中，我们将适应和 评估集中干预措施，包括确定的护理途径和筛查后护理协调 衡量对坚持和社会经济、城乡和种族之间差异的影响。终于在 第三个目标，我们将评估这些战略的实施情况，重点关注以下方面的紧张关系： 随着这些干预措施的成熟，这些目标将立足于综合 实施研究的综合框架，RE-AIM和NIH开发的健康差异 框架.我们的团队在肺癌筛查实施和差异方面拥有丰富的经验， 在适应和评估社区环境中的务实干预措施方面的专业知识。该项目将产生 在现实世界的临床项目中改善肺癌筛查随访的基本知识。

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.