Multilevel Interventions to Increase Adherence to Lung Cancer Screening

摘要 肺癌筛查有可能对公众健康产生深远的影响。肺癌是最主要的 美国男性和女性癌症发病率和死亡率的原因，导致的死亡人数超过乳腺癌， 宫颈癌、结直肠癌和前列腺癌加在一起。每年一次的低剂量CT筛查 低密度CT(LDCT)将肺癌死亡率降低了20%。成功的基于人群的筛查需要持续不断 监测高危成人的依从性重复筛查以达到类似的结果。每年重复 筛查对于肺癌的早期发现是必要的。基线或首次LDCT扫描发现流行的肺部 癌症，当随后的筛查发现新的结节时。然而，对筛查的依从性很低，范围在 28%-38%来自全国中心。针对患者、临床医生和医疗保健的多层次干预 系统，提供了一个有希望的框架，以解决肺癌筛查方面的空白，以实现指南- 建议进行肺癌筛查。我们对KPWA利益相关者进行的混合方法试点研究 提高重复筛查依从性的要素：为肺癌患者提供教育 筛查，并提供及时返回筛查的提醒。我们开发了两种新的以患者为中心的 使用以人为中心的设计原则来满足这些需求的干预措施：1)患者的声音视频 合并了患者证明以确认收到筛查，这是一个定制的提醒，表明下一次筛查的时间 扫描和保证，以减少对筛查的恐惧和亲人在支持健康选择方面的作用；以及2) 阶梯式提醒，直接提醒患者下一次扫描的时间。这两种干预措施都是 由卫生系统电子健康记录(EHR)提供便利，以跟踪患者的人口健康 管理和临床嵌入的医疗助理提供干预。这项提议的目标是 为了检验这两种干预措施相对于平时的护理，促进在务实的情况下坚持重复筛查 整群随机试验招募了1775名成年KPWA成员，他们在2022-2025年完成了LDCT筛查 在一项2x2析因设计的研究中，覆盖了34家KPWA初级保健诊所。学习臂包括：a)阶梯 单独的提醒；b)单独的患者声音视频；c)两种干预措施；或d)常规护理。为了实现我们的目标， 我们的具体目标是：1)比较两种多水平干预措施相对于常规护理的有效性 提高(A)坚持肺癌筛查的比率；(B)以患者为中心的结果；和(C)临床 结果；以及2)确定影响变化的患者、临床医生和系统级别的因素 坚持为肺癌筛查项目提供信息。到目前为止，还没有随机临床试验评估过 采用多层次策略提高美国人群肺癌筛查依从性的策略。我们会 通过提供有效的、可扩展的干预措施来改进肺癌筛查，推动该领域的发展 坚持实现基于人群的死亡率收益，这是大型临床试验承诺的 筛查指南。

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.