Lung Cancer Survival Trends in the Veterans Health Administration.

INTRODUCTION: Lung cancer survival is improving in the United States. We investigated whether there was a similar trend within the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States. MATERIALS AND METHODS: Data from the Veterans Affairs Central Cancer Registry were analyzed for temporal survival trends using Kaplan-Meier estimates and linear regression. RESULTS: A total number of 54,922 Veterans were identified with lung cancer diagnosed from 2010 to 2017. Histologies were classified as non-small-cell lung cancer (NSCLC) (64.2%), small cell lung cancer (SCLC) (12.9%), and 'other' (22.9%). The proportion with stage I increased from 18.1% to 30.4%, while stage IV decreased from 38.9% to 34.6% (both P < .001). The 3-year overall survival (OS) improved for stage I (58.6% to 68.4%, P < .001), stage II (35.5% to 48.4%, P < .001), stage III (18.7% to 29.4%, P < .001), and stage IV (3.4% to 7.8%, P < .001). For NSCLC, the median OS increased from 12 to 21 months (P < .001), and the 3-year OS increased from 24.1% to 38.3% (P < .001). For SCLC, the median OS remained unchanged (8 to 9 months, P = .10), while the 3-year OS increased from 9.1% to 12.3% (P = .014). Compared to White Veterans, Black Veterans with NSCLC had similar OS (P = .81), and those with SCLC had higher OS (P = .003). CONCLUSION: Lung cancer survival is improving within the VHA. Compared to White Veterans, Black Veterans had similar or higher survival rates. The observed racial equity in outcomes within a geographically and socioeconomically diverse population warrants further investigation to better understand and replicate this achievement in other healthcare systems.

Breast Cancer Screening in the Intermediate-Risk Population: Falling Through the Cracks?

Breast cancer screening guidelines vary for women at intermediate risk (15%-20% lifetime risk) for developing breast cancer across jurisdictions. Currently available risk assessment models have differing strengths and weaknesses, creating difficulty and ambiguity in selecting the most appropriate model to utilize. Clarifying which model to utilize in individual circumstances may help determine the best screening guidelines to use for each individual.

Resident Attitudes and Experiences with a Novel Radiology-based Transgender Curriculum: A Qualitative Study.

RATIONALE AND OBJECTIVES: Transgender persons often experience healthcare disparities due to lack of provider knowledge. With increasing gender diversity awareness and prevalence of gender-affirming care, radiologists-in-training need to be aware of the unique health considerations for this patient population. Radiology residents have limited exposure to dedicated teaching on transgender medical care and imaging during training. Development and implementation of a radiology-based transgender curriculum can help close this gap in radiology residency education. The aim of this study was to explore radiology resident attitudes and experiences with a novel radiology-based transgender curriculum, guided by the conceptual framework of reflective practice. MATERIALS AND METHODS: A qualitative approach was employed using semi-structured interviews to explore resident perspectives of a curriculum covering transgender patient care and imaging over 4 monthly sessions. Ten residents at the University of Cincinnati radiology residency participated in interviews consisting of open-ended questions. Interviews were audiotaped, transcribed, and thematic analysis was conducted across all responses. RESULTS: Four themes emerged through the existing framework: 1) impactful/memorable aspects; things learned; increased awareness; and suggestions/feedback. Prominent subthemes included patient panel and stories, physician experts sharing knowledge and experiences, link to radiology and imaging, novel concept, gender-affirming surgeries and anatomy, appropriate radiology reporting, and patient interactions. CONCLUSION: Radiology residents found the curriculum to be an effective novel educational experience that was previously unaddressed during their training. This imaging-based curriculum can be further adapted and implemented in a variety of radiology curricular settings.

Social Determinants of Health in Imaging-based Cancer Screening: A Case-based Primer with Strategies for Care Improvement.

Health disparities, preventable differences in the burden of disease and disease outcomes often experienced by socially disadvantaged populations, can be found in nearly all areas of radiology, including emergency radiology, neuroradiology, nuclear medicine, image-guided interventions, and imaging-based cancer screening. Disparities in imaging-based cancer screening are especially noteworthy given the far-reaching population health impact. The social determinants of health (SDoH) play an important role in disparities in cancer screening and outcomes. Through improved understanding of how SDoH can drive differences in health outcomes in radiology, radiologists can effectively provide patient-centered, high-quality, and equitable care. Radiologists and radiology practices can become active partners in efforts to assist patients along their imaging journey and overcome existing barriers to equitable cancer screening care for traditionally marginalized populations. As radiology exists at the intersection of diagnostic imaging, image-guided diagnostic intervention, and image-guided treatment, radiologists are uniquely positioned to design these strategies. Cost-effective and socially conscious strategies that address barriers to equitable care can improve both public health and equitable health outcomes. Potential strategies include championing supportive health policy, reducing out-of-pocket costs, increasing price transparency, improving education and outreach efforts, ensuring that appropriate language translation services are available, providing individualized assistance with appointment scheduling, and offering transportation assistance and childcare. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Rural barriers and facilitators of lung cancer screening program implementation in the veterans health administration: a qualitative study.

Introduction: To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members. Methods: Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation. Results: A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior. Discussion: Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings.

Canadian radiology workforce demographics: Results from a national survey.

Rationale and objective: Demographic data collected about Canadian radiologists and trainees has been limited primarily to binary gender and geographic location. The purpose of this study was to investigate: (1) demographic characteristics of Canadian radiologists and trainees; (2) types of diversity important to radiologists; (3) relationship of radiologist demographics to practice characteristics; and (4) relationship of radiologist demographics to years in practice, (YIP). Materials and methods: French and English surveys were distributed via email through radiology associations and social media. Frequency counts of demographic variables were calculated, and chi-square and Fisher's Exact tests were performed to explore the relationships between demographic characteristics and role. Results: 611 individuals responded to the survey. 573 respondents were included in the analysis. 454 (78.8%) were practicing radiologists and 119 (20.7%) were residents/fellows. Half identified as women (50.4%). English was the primary language for most respondents. There was an association between role and sexual orientation (p = 0.02), visible minority (χ2 = 4.79, p < 0.05), religion (χ2 = 4.11, p < 0.05), and having children (χ2 = 136.65, p < 0.05). For radiologists, being a visible minority (χ2 = 11.59, p < 0.05) and age (χ2 = 56.3, p < 0.05) were associated with academic rank while gender (χ2 = 3.83, p < 0.05) and age (χ2 = 13.74, p < 0.05) were related to part-/full-time status. Less women, visible minorities, and women with children had been in practice for long. Discussion: This study represents a comprehensive analysis of Canadian radiology demographics. Results suggest there is increasing diversity among trainees; however, significant demographic underrepresentation compared to the diversity of Canada exists.

Fostering Patient-Centered Equitable Care in Radiology: AJR Expert Panel Narrative Review.

Patient-centered care (PCC) and equity are two of the six core domains of quality health care, according to the Institute of Medicine. Exceptional imaging care requires radiology practices to provide patient-centered (i.e., respectful and responsive to individual patient preferences, needs, and values) and equitable (i.e., does not vary in quality on the basis of gender, ethnicity, geographic location, or socioeconomic status) care. Specific barriers that prevent the delivery of patient-centered equitable care include information gaps, breaches of trust, organizational medical culture, and financial incentives. Information gaps limit practitioners in understanding the lived experience of patients. Breaches of trust prevent patients from seeking needed medical care. Organizational medical cultures may not be centered around patient experiences. Financial incentives can impede practitioners' ability to spend the time and resources required to meet patient goals and needs. Intentional approaches that integrate core principles in both PCC and health equity are required to deliver high-quality patient-centered imaging care for diverse patient populations. The purpose of this AJR Expert Panel Narrative Review is to review the origins of the PCC movement in radiology, characterize connections between the PCC and health equity movements, and describe concrete examples of ways to foster patient-centered equitable care in radiology.

APDR Healthcare Disparities Curriculum Pilot: Helping Trainees Meet More Than a Milestone.

RATIONALE AND OBJECTIVES: In order to help program directors satisfy the Accreditation Council for Graduate Medical Education common program requirement for health care disparities (HCD) education, a comprehensive web-based curriculum on HCDs in Radiology was developed. The curriculum was designed to educate trainees about existing HCDs, stimulate discussion, and spur research about HCDs in radiology. The curriculum was piloted to assess its educational value and feasibility. MATERIAL AND METHODS: A comprehensive curriculum comprised of four modules (1) Introduction to HCDs in Radiology, (2) Types of HCDs in Radiology, (3) Actions to Address HCDs in Radiology, and (4) Cultural Competency was created and housed on the Associate of Program Directors in Radiology website. Various educational media including recorded lectures or PowerPoint presentations, small group discussions, and journal clubs were employed. A pilot program was initiated to evaluate the benefits of this curriculum for resident education and consisted of a pre- and post-curriculum test for trainees, an experience survey for trainees, and a pre- and post-administration survey for facilitators. RESULTS: Forty-seven radiology residency programs participated in the pilot of the HCD curriculum. Of those facilitating the curriculum, 83% indicated lack of standardized curriculum as a perceived barrier to implementing a HCD curriculum at their program on the pre-survey. Trainee knowledge scores increased from 65% (pre) to 67% (post) (p = 0.05). Following curriculum participation, residents indicated an increase in adequate understanding of HCDs in Radiology (81% post vs. 45% pre). Most program directors (75%) found the curriculum easy to implement. CONCLUSION: This pilot study demonstrated that the APDR Health Care Disparities curriculum increased trainee awareness of HCDs. The curriculum also provided a forum for important discussions about HCDs.

The Association of Organizational Readiness With Lung Cancer Screening Utilization.

INTRODUCTION: Lung cancer screening is widely underutilized. Organizational factors, such as readiness for change and belief in the value of change (change valence), may contribute to underutilization. The aim of this study was to evaluate the association between healthcare organizations' preparedness and lung cancer screening utilization. METHODS: Investigators cross-sectionally surveyed clinicians, staff, and leaders at10 Veterans Affairs from November 2018 to February 2021 to assess organizational readiness to implement change. In 2022, investigators used simple and multivariable linear regression to evaluate the associations between facility-level organizational readiness to implement change and change valence with lung cancer screening utilization. Organizational readiness to implement change and change valence were calculated from individual surveys. The primary outcome was the proportion of eligible Veterans screened using low-dose computed tomography. Secondary analyses assessed scores by healthcare role. RESULTS: The overall response rate was 27.4% (n=1,049), with 956 complete surveys analyzed: median age of 49 years, 70.3% female, 67.6% White, 34.6% clinicians, 61.1% staff, and 4.3% leaders. For each 1-point increase in median organizational readiness to implement change and change valence, there was an associated 8.4-percentage point (95% CI=0.2, 16.6) and a 6.3-percentage point increase in utilization (95% CI= -3.9, 16.5), respectively. Higher clinician and staff median scores were associated with increased utilization, whereas leader scores were associated with decreased utilization after adjusting for other roles. CONCLUSIONS: Healthcare organizations with higher readiness and change valence utilized more lung cancer screening. These results are hypothesis generating. Future interventions to increase organizations' preparedness, especially among clinicians and staff, may increase lung cancer screening utilization.

An Upstream Reparative Justice Framework for Improving Diversity in Radiology.

Health care workforce diversity is vital in combating health disparities. Despite much recent attention to downstream strategies to improve diversity in radiology, such as increased recruitment efforts and holistic application review, workforce diversity has not tangibly improved in recent decades. Yet, little discussion has been devoted to defining the obstacles that might delay, complicate, or altogether prevent persons from groups that have been traditionally marginalized and minoritized from a career in radiology. Refocusing attention to upstream barriers to medical education is vital to develop sustainable workforce diversity efforts in radiology. The purpose of this article is to highlight the varied obstacles students and trainees from historically underrepresented communities may face along the radiology career pathway and to provide concrete corollary programmatic solutions. Using a reparative justice framework, which encourages race- and gender-conscious repair of historical injustices, and the socioecological model, which recognizes an individual's choices are informed by historical and ongoing systems of power, this article advocates for tailored programs to improve justice, equity, diversity, and inclusion in radiology.

Prevalence of Diversity Statements and Disability Inclusion Among Radiology Residency Program Websites.

INTRODUCTION: Radiology has widely acknowledged the need to improve inclusion of racial, ethnic, gender, and sexual minorities, with recent discourse also underscoring the importance of disability diversity and inclusion efforts. Yet studies have shown a paucity of diversity among radiology residents, despite increasing efforts to foster diversity and inclusion. Thus, the purpose of this study is to assess radiology residency program websites' diversity statements for inclusion of race and ethnicity, gender, sexual orientation, and disability as commonly underrepresented groups. METHODS: A cross-sectional, observational study of websites of all diagnostic radiology programs in the Electronic Residency Application Service directory was conducted. Program websites that met inclusion criteria were audited for presence of a diversity statement; if the statement was specific to the residency program, radiology department, or institution; and if it was presented or linked on the program or department website. All statements were evaluated for the inclusion of four diversity categories: race or ethnicity, gender, sexual orientation, and disability. RESULTS: One hundred ninety-two radiology residencies were identified using Electronic Residency Application Service. Programs with missing or malfunctioning hyperlinks (n = 33) or required logins (n = 1) were excluded. One hundred fifty-eight websites met inclusion criteria for analysis. Two-thirds (n = 103; 65.1%) had a diversity statement within their residency, department, or institution, with only 28 (18%) having residency program-specific statements and 22 (14%) having department-specific statements. Of the websites with diversity statements, inclusion of gender diversity was most frequent (43.0%), followed by race or ethnicity (39.9%), sexual orientation (32.9%), and disability (25.3%). Race or ethnicity was most included in institution-level diversity statements. CONCLUSIONS: Less than 20% of radiology residency websites include a diversity statement, and disability is the least-included category among the diversity statements. As radiology continues to lead diversity and inclusion efforts in health care, a more comprehensive approach with equitable representation of different groups, including those with disabilities, would foster a broader sense of belonging. This comprehensive approach can help to overcome systemic barriers and bridge gaps in disability representation.

Beyond the Binary: Moving the Radiology Workforce Toward Gender Inclusion, From the AJR Special Series on DEI.

Gender representation in radiology has traditionally been evaluated and reported through binary models, accompanied by advocacy efforts focused on increasing the number of women in radiology. A paucity of data exists to understand the entire gender composition of the radiology workforce, including representation of people who are transgender and gender diverse. Further, little information exists on how to provide a supportive work environment for radiologists and support staff who identify as belonging to an underrepresented gender minority group. Intentional efforts to comprehensively understand the gender representation of the radiology workforce can help to establish a diverse workforce that is more representative of the patient populations that we serve, while promoting high-quality inclusive health care. Moving beyond gender binary thought and practices can help foster a culture of inclusion and belonging in radiology. This article provides practical steps that radiology practices can take to understand and support gender diversity beyond the binary in the radiology workforce, including providing definitions and inclusive language, understanding limitations of historical methods of gender data collection in radiology and relevant published literature, establishing best practices for future data collection, and developing a strategic vision with action items to create a more inclusive work environment.

Black Women's Perspectives on Breast Cancer Risk Assessment.

PURPOSE: The aim of this study was to gather the perspectives of Black women on breast cancer risk assessment through a series of one-on-one interviews. METHODS: The authors conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with Black women in Tennessee between September 2020 and November 2020. Guided by the Health Belief Model, qualitative analysis of interview data was performed in an iterative inductive and deductive approach and resulted in the development of a conceptual framework to depict influences on a woman's decision to engage with breast cancer risk assessment. RESULTS: A total of 37 interviews were completed, and a framework of influences on a woman's decision to engage in breast cancer risk assessment was developed. Study participants identified several emerging themes regarding women's perspectives on breast cancer risk assessment and potential influences on women's decisions to engage with risk assessment. Much of women's decision context was based on risk appraisal (perceived severity of cancer and susceptibility of cancer), emotions (fear and trust), and perceived risks and benefits of having risk assessment. The decision was further influenced by modifiers such as communication, the risk assessment protocol, access to health care, knowledge, and health status. Perceived challenges to follow-up if identified as high risk also influenced women's decisions to pursue risk assessment. CONCLUSIONS: Black women in this study identified several barriers to engagement with breast cancer risk assessment. Efforts to overcome these barriers and increase the use of breast cancer risk assessment can potentially serve as a catalyst to address existing breast cancer disparities. Continued work is needed to develop patient-centric strategies to overcome identified barriers.

Barriers to Implementation of Breast Cancer Risk Assessment: The Health Care Team Perspective.

PURPOSE: To assess health care professionals' perceptions of barriers to the utilization of breast cancer risk assessment tools in the public health setting through a series of one-on-one interviews with health care team members. METHODS: We conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with health care team members in the public health setting in the state of Tennessee between May 2020 and October 2020. An iterative inductive-deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual framework to depict influences of provider behavior in the utilization of breast cancer risk assessment. RESULTS: A total of 24 interviews were completed, and a framework of influences of provider behavior in the utilization of breast cancer risk assessment was developed. Participants identified barriers to the utilization of breast cancer risk assessment (knowledge and understanding of risk assessment tools, workflow challenges, and availability of personnel); patient-level barriers as perceived by health care team members (psychological, economic, educational, and environmental); and strategies to increase the utilization of breast cancer risk assessment at the provider level (leadership buy-in, training, supportive policies, and incentives) and patient level (improved communication and better understanding of patients' perceived cancer risk and severity of cancer). CONCLUSIONS: Understanding barriers to implementation of breast cancer risk assessment and strategies to overcome these barriers as perceived by health care team members offers an opportunity to improve implementation of risk assessment and to identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.

A Framework for Developing Health Equity Initiatives in Radiology.

PURPOSE: In recent years, radiology departments have increasingly recognized the extent of health care disparities related to imaging and image-guided interventions. The goal of this article is to provide a framework for developing a health equity initiative in radiology and to articulate key defining factors. METHODS: This article leverages the experience of three academic radiology departments and explores key principles that emerged when observing the experiences of these departments that have begun to engage in health equity-focused work. RESULTS: A four-component framework is described for a health equity initiative in radiology consisting of (1) environmental scan and blueprint, (2) design and implementation, (3) initiative evaluation, and (4) community engagement. Key facilitators include a comprehensive environmental scan, early stakeholder engagement and consensus building, implementation science design thinking, and multitiered community engagement. CONCLUSIONS: All radiology organizations should strive to develop, pilot, and evaluate novel initiatives that promote equitable access to high-quality imaging services. Establishing systems for high-quality data collection is critical to success. An implementation science approach provides a robust framework for developing and testing novel health equity initiatives in radiology. Community engagement is critical at all stages of the health equity initiative time line.

Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study adaptations in lung cancer screening delivery in the Veterans Health Administration: a cohort study.

BACKGROUND: Lung cancer screening is a complex clinical process that includes identification of eligible individuals, shared decision-making, tobacco cessation, and management of screening results. Adaptations to the delivery process for lung cancer screening in situ are understudied and underreported, with the potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for a systematic enumeration of adaptations to implementation of evidence-based practices. We applied FRAME to study adaptations in lung cancer screening delivery processes implemented by lung cancer screening programs in a Veterans Health Administration (VHA) Enterprise-Wide Initiative. METHODS: We prospectively conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMCs) between 2019 and 2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, documented, and mapped to FRAME categories. RESULTS: We conducted a total of 16 interviews across 10 VHA lung cancer screening programs (n=6 in year 1, n=10 in year 2) to collect adaptations. In year 1 (2020), six programs were operational and eligible. Of these, three reported adaptations to their screening process that were planned or in response to COVID-19. In year 2 (2021), all 10 programs were operational and eligible. Programs reported 14 adaptations in year 2. These adaptations were planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to the identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 60% of programs to improve the data collection and tracking of Veterans in the screening process. CONCLUSIONS: Using FRAME, we found that adaptations occurred primarily in the areas of patient identification and communication of results due to increased workload. These findings highlight navigator time and resource considerations for sustainability and scalability of existing and future lung cancer screening programs as well as potential areas for future intervention.

Practical Approaches to Advancing Health Equity in Radiology, From the AJR Special Series on DEI.

Despite significant advances in health care, many patients from medically under-served populations are impacted by existing health care disparities. Radiologists are uniquely positioned to decrease health disparities and advance health equity efforts in their practices. However, literature on practical tools for advancing radiology health equity efforts applicable to a wide variety of patient populations and care settings is lacking. Therefore, this article seeks to equip radiologists with an evidence-based and practical knowledge tool kit of health equity strategies, presented in terms of four pillars of research, clinical care, education, and innovation. For each pillar, equity efforts across diverse patient populations and radiology practice settings are examined through the lens of existing barriers, current best practices, and future directions, incorporating practical examples relevant to a spectrum of patient populations. Health equity efforts provide an opportune window to transform radiology through personalized care delivery that is responsive to diverse patient needs. Guided by compassion and empathy as core principles of health equity, the four pillars provide a helpful framework to advance health equity efforts as a step toward social justice in health.