Implementing Shared Decision-Making for Cancer Screening in Primary Care

甚至比其他筛查服务更难知道哪些患者最有可能受益 来自肺癌筛查(LCS)。更困难的是向患者解释筛查的权衡 特别是在讨论预防服务的时间限制在5分钟以内的情况下 在一次忙碌的访问中。决策支持可以有所帮助，但必须包含3个关键功能才能最大限度地提高效率和 可持续：1)准确估计LCS对个别患者的益处；2)设计 以及包含知情利益相关者(临床医生、退伍军人管理局领导人和 退伍军人)和在繁忙的诊所就诊期间常规进行个性化筛查的实用方法；以及3)设计 这优化了该工具与退伍军人管理局临床工作流程的匹配。在我的导师和指导委员会的合作下， 我建议开展一项工作，该工作将利用我共同领导的一个项目并在此基础上进行实质性的建设--Ann Arbor 退伍军人管理局资助的证明QUERI-研究更传统的共享决定的快速实施- 制作(SDM)工具仅配备第一个功能(LCS收益的个性化估计)。要实现 这些目标CDA有3个目标。 目标1--评估知情的利益攸关方意见(3个项目)：在这个目标中，我将采用民主审议 广泛告知和接触LCS的主要利益相关者，以了解他们对以下方面的意见/建议 提出并讨论LCS。在项目1a(“临床论坛”)中，我将招募一个由12-15名临床利益相关者组成的小组 (PCP、筛查协调员和临床负责人)来自全国范围内的退伍军人事务部，告知他们 LCS使他们受益，并使他们参与审议，获得他们对以下各项的“简单边界规则”的建议 筛查时应鼓励、不鼓励，还是完全由L患者选择。在项目1b(2“退伍军人 论坛“)我将从10名符合LCS资格的退伍军人中随机抽取，进行2次 单独的为期一天的论坛。核心目标将是利用2名不同观点的内容专家来 告知退伍军人实施LCS的挑战和临床实践的限制，然后 获得个人和团体的“简单操作规则”建议，临床医生可以用来让患者参与其中 在LCS讨论中，考虑到PCP面临的相互竞争的需求。在项目1c中，我将使用风险沟通理论。 开发包含退伍军人事务部利益相关者指导的创新工具功能，并可帮助指导 临床医生如何有效地个性化LCS。 目标2--优化决策支持与退伍军人事务部临床环境相适应(2个项目)：在项目2a中，我将 对多个Proven QuUERI数据流进行综合分析，以了解LCS决策 可以重新设计支持，以克服实施挑战并增强工具使用的动力。然后, 在项目2b中，我探索了维基调查作为一种新的方法，让临床利益相关者参与进来：1)评估新的 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) 帮助确定要包含在升级工具中的策略和内容的优先顺序。 目标3-试点(3个项目)：在目标1和目标2的通知下，我将在项目3a中开发一个纸质原型。 然后，在项目3b中，我将通过进行5-8次受监控的模拟临床会议(每个模拟 会面将包括一名患者、一名初级保健医生和一名PACT工作人员)。在项目3c中，我将使用30个 有目的地从6个不同的门诊VA设置中抽样的PCP。每个PCP将首先收到1对1 教育干预。然后，我将通过2-3个LC测试我的纸面决策支持的可行性- 每个参与的PCP有资格的退伍军人。将对相遇进行录音，以评估 LCS讨论。专科医生和患者将完成调查和访谈，以评估满意度和舒适度 参与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度的 高质量的个性化LCS讨论，同时可接受不同样本的PCP和退伍军人。

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.