Multilevel Interventions to Increase Adherence to Lung Cancer Screening

摘要 肺癌筛查有可能带来深远的公共卫生益处。肺癌是主要的 美国男性和女性癌症发病率和死亡率的原因，比乳腺癌死亡率高， 宫颈癌、结肠直肠癌和前列腺癌。低剂量计算机断层扫描的年度筛查 （LDCT）降低肺癌死亡率20%。成功的基于人群的筛查需要持续的 在高危成人中进行重复筛查，以获得类似的结果。每年重复 要及早发现肺癌，检查是必需的。基线或首次LDCT扫描检测到普遍的肺部 癌症，当随后的筛查检测到新的结节时。然而，筛查的依从性很低， 28-38%来自全国各地的中心。针对患者、临床医生和医疗保健的多层次干预 系统，提供了一个有前途的框架，以解决肺癌筛查的差距，以实现指导方针- 推荐的肺癌筛查。我们与KPWA利益相关者的混合方法试点研究有两个关键 提高重复筛查依从性的组成部分：为肺癌患者提供教育 筛选，并提供及时返回筛选提醒。我们开发了两种新的以患者为中心的 采用以人为本的设计原则进行干预，以满足这些需求：1）患者的声音视频， 包含患者的证明，以确认接受筛查，这是一个量身定制的提醒，提醒下一次检查的时间 扫描和保证，以减少对筛查的恐惧，以及亲人在支持健康选择方面的作用;以及2） 分步提醒，直接提醒患者下一次扫描的时间。这两种干预措施都是 通过建立卫生系统电子健康记录（EHR）来跟踪患者的人群健康 管理和临床嵌入式医疗助理提供干预措施。这项提案的目的是 测试这两种干预措施相对于常规护理，以促进坚持重复筛查， 一项随机分组试验，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因子设计的研究中，在34个KPWA初级保健诊所中进行了研究。研究组包括： 仅提醒; B）仅患者语音视频; c）两种干预;或d）常规护理。为了实现我们的目标， 我们的具体目标是：1）比较两种多层次干预措施相对于常规护理的有效性， 提高（a）肺癌筛查依从率，（B）以患者为中心的结局;以及（c）临床 结果;和2）确定患者，临床医生和系统水平的因素，影响的变化， 坚持告知肺癌筛查计划。到目前为止，还没有随机临床试验评估 多层次策略提高美国人群肺癌筛查依从性的策略。我们将 通过提供有效的、可扩展的干预措施来改善肺癌筛查， 坚持以实现大型临床试验所承诺的基于人群的死亡率获益， 筛选指南。

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.