Progressing towards implementation of lung cancer screening in the VHA

对退伍军人医疗保健的预期影响：VHA服务的退伍军人患病率较高 肺癌的死亡率也高于普通人群。最近的全国肺部筛查试验 (NLST)显示肺癌死亡率降低20%，全因死亡率降低7% 55-74岁吸烟者的年度胸部CT检查。据此，提出了几种新的临床应用 实践指南建议对中年吸烟者进行CT筛查-这一群体将包括 数百万退伍军人。肺癌的CT筛查具有降低肺癌死亡率的令人兴奋的潜力，但 此外，VHA的巨大成本和退伍军人的不良后果如果不在 深思熟虑的时尚。拟议的工作对我们的业务合作伙伴国家 肿瘤学和肺病学项目办公室和国家健康促进和疾病中心 预防，已由卫生局副局长负责进行临床演示 在VHA实施肺癌筛查项目。 背景：尽管CT筛查在降低肺癌死亡率方面的效果令人印象深刻，但 这也有不利的一面。在CT组，几乎40%的NLST参与者有一个肺结节被检测到 需要进一步的评估才能排除癌症--其中95%的结果是假阳性。 评估肺结节的指南很复杂，要求临床医生在CT 监护、正电子发射计算机断层扫描、经胸针活检、支气管镜活检和手术切除； VHA内部或私营部门始终遵循这一原则。与此同时，需要手术的患者 如果在具有胸部外科专业知识的中心进行手术，切除效果会更好。鉴于这些， 因素，指南建议，肺癌筛查应在“综合性的”中心进行。 用于潜在癌症的筛查以及下游评估和治疗的过程。 供应商认为筛查的证据是可靠的，哪些网站具有适当的本地背景以 确保全面肺癌筛查计划的成功实施是未知的。 目标：为了满足我们业务伙伴的需求，并遵循修订后的PARIHS框架，我们 建议评估与实施肺癌筛查相关的证据、背景和促进者 VHA中的计划。这将为肺癌筛查计划的实施地点选择提供信息， 为这些站点量身定制基于需求的实施策略，并规划和执行临床 由我们的运营合作伙伴牵头的肺癌筛查示范项目。 方法：目标1：我们将对所有VAMC肺科医生进行在线调查，以评估对 在其现场实施肺癌筛查的证据和当地背景。目标2：我们将进行 诊断形成性评估2个VA站点已经实施了肺癌筛查计划，以 告知临床示范项目的规划和实施情况，然后进行第三次、 在6个临床示范项目点之一进行以实施为重点的形成性评估以进行评估 成功实施。

Anticipated Impacts on Veterans Health Care: Veterans served by the VHA suffer both higher prevalence and higher mortality from lung cancer than the general population. The recent National Lung Screening Trial (NLST) demonstrated a 20% reduction in lung cancer mortality and a 7% reduction in all cause mortality with annual chest CT screening among current and former smokers aged 55-74. Accordingly, several new clinical practice guidelines recommend CT screening for middle-aged smokers - a group which would encompass millions of Veterans. CT screening for lung cancer has the exciting potential to reduce lung cancer death, but also the potential for huge costs to the VHA and adverse outcomes for Veterans if not implemented in a thoughtful fashion. The proposed work is of critical importance to our operational partners, the National Program Offices for Oncology and Pulmonology and the National Center for Health Promotion & Disease Prevention, who have been tasked by the Under Secretary for Health with conducting a clinical demonstration project of implementation of lung cancer screening in the VHA. Background: Despite the impressive efficacy of CT screening at reducing lung cancer mortality, CT screening also has downsides. Almost 40% of NLST participants in the CT arm had a pulmonary nodule detected that required further evaluation to rule out cancer - and 95% of those turned out to be false positive findings. Guidelines for pulmonary nodule evaluation are complex, requiring clinicians to choose between CT surveillance, PET scan, transthoracic needle biopsy, bronchoscopic biopsy, and surgical resection; and are not consistently followed either inside the VHA or in the private sector. Meanwhile, patients who require surgical resection have better outcomes if operated on in centers with expertise in thoracic surgery. In light of these factors, guidelines recommend that lung cancer screening be conducted in centers with a "comprehensive process" for both screening as well as downstream evaluation and treatment of potential cancers. Whether VA providers perceive the evidence for screening as robust and which sites have the local context in place to ensure successful implementation of comprehensive lung cancer screening programs is unknown. Objectives: To meet the needs of our operational partners and following the revised PARIHS framework, we propose to assess the evidence, context, and facilitators relevant to implementation of lung cancer screening programs in the VHA. This will inform selection of sites for implementation of lung cancer screening programs, tailoring of needs-based implementation strategies for these sites, and planning and execution of the clinical demonstration project of lung cancer screening that our operational partners are leading. Methods: Aim 1: We will conduct an online survey of all VAMC pulmonologists to assess perceptions of evidence and local context for implementation of lung cancer screening at their site. Aim 2: We will conduct diagnostic formative evaluations 2 VA sites that have already implemented lung cancer screening programs to inform planning and implementation of the clinical demonstration project, and then conduct a 3rd, implementation-focused formative evaluation at one of the 6 clinical demonstration project sites to assess success of implementation.