Engaging Operational Partners Is Critical for Successful Implementation of Research Products: a Coincidence Analysis of Access-Related Projects in the Veterans Affairs Healthcare System.

BACKGROUND/OBJECTIVE: The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research into practice remains challenging. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation. DESIGN: We conducted a portfolio review of recent VHA-funded or supported projects (1/2015-7/2020) focused on healthcare access ("Access Portfolio"). We then identified projects with implementable research deliverables by excluding those that (1) were non-research/operational projects; (2) were only recently completed (i.e., completed on or after 1/1/2020, meaning that they were unlikely to have had time to be implemented); and (3) did not propose an implementable deliverable. An electronic survey assessed each project's implementation status and elicited barriers/facilitators to implementing deliverables. Results were analyzed using novel Coincidence Analysis (CNA) methods. PARTICIPANTS/KEY RESULTS: Among 286 Access Portfolio projects, 36 projects led by 32 investigators across 20 VHA facilities were included. Twenty-nine respondents completed the survey for 32 projects (response rate = 88.9%). Twenty-eight percent of projects reported fully implementing project deliverables, 34% reported partially implementing deliverables, and 37% reported not implementing any deliverables (i.e., resulting tool/intervention not implemented into practice). Of 14 possible barriers/facilitators assessed in the survey, two were identified through CNA as "difference-makers" to partial or full implementation of project deliverables: (1) engagement with national VHA operational leadership; (2) support and commitment from local site operational leadership. CONCLUSIONS: These findings empirically highlight the importance of operational leadership engagement for successful implementation of research deliverables. Efforts to strengthen communication and engagement between the research community and VHA local/national operational leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care. The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research findings into clinical practice remains challenging, both within and outside VHA. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation. Only two factors were identified as "difference-makers" to adoption of project findings into practice: (1) engagement with national VHA leadership or (2) support and commitment from local site leadership. These findings highlight the importance of leadership engagement for successful implementation of research findings. Efforts to strengthen communication and engagement between the research community and VHA local/national leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care.

Factors Associated With Declining Lung Cancer Screening After Discussion With a Physician in a Cohort of US Veterans.

Importance: Lung cancer screening (LCS) is underused in the US, particularly in underserved populations, and little is known about factors associated with declining LCS. Guidelines call for shared decision-making when LCS is offered to ensure informed, patient-centered decisions. Objective: To assess how frequently veterans decline LCS and examine factors associated with declining LCS. Design, Setting, and Participants: This retrospective cohort study included LCS-eligible US veterans who were offered LCS between January 1, 2013, and February 1, 2021, by a physician at 1 of 30 Veterans Health Administration (VHA) facilities that routinely used electronic health record clinical reminders documenting LCS eligibility and veterans' decisions to accept or decline LCS. Data were obtained from the Veterans Affairs (VA) Corporate Data Warehouse or Medicare claims files from the VA Information Resource Center. Main Outcomes and Measures: The main outcome was documentation, in clinical reminders, that veterans declined LCS after a discussion with a physician. Logistic regression analyses with physicians and facilities as random effects were used to assess factors associated with declining LCS compared with agreeing to LCS. Results: Of 43 257 LCS-eligible veterans who were offered LCS (mean [SD] age, 64.7 [5.8] years), 95.9% were male, 84.2% were White, and 37.1% lived in a rural zip code; 32.0% declined screening. Veterans were less likely to decline LCS if they were younger (age 55-59 years: odds ratio [OR], 0.69; 95% CI, 0.64-0.74; age 60-64 years: OR, 0.80; 95% CI, 0.75-0.85), were Black (OR, 0.80; 95% CI, 0.73-0.87), were Hispanic (OR, 0.62; 95% CI, 0.49-0.78), did not have to make co-payments (OR, 0.92; 95% CI, 0.85-0.99), or had more frequent VHA health care utilization (outpatient: OR, 0.70; 95% CI, 0.67-0.72; emergency department: OR, 0.86; 95% CI, 0.80-0.92). Veterans were more likely to decline LCS if they were older (age 70-74 years: OR, 1.27; 95% CI, 1.19-1.37; age 75-80 years: OR, 1.93; 95% CI, 1.73-2.17), lived farther from a VHA screening facility (OR, 1.06; 95% CI, 1.03-1.08), had spent more days in long-term care (OR, 1.13; 95% CI, 1.07-1.19), had a higher Elixhauser Comorbidity Index score (OR, 1.04; 95% CI, 1.03-1.05), or had specific cardiovascular or mental health conditions (congestive heart failure: OR, 1.25; 95% CI, 1.12-1.39; stroke: OR, 1.14; 95% CI, 1.01-1.28; schizophrenia: OR, 1.87; 95% CI, 1.60-2.19). The physician and facility offering LCS accounted for 19% and 36% of the variation in declining LCS, respectively. Conclusions and Relevance: In this cohort study, older veterans with serious comorbidities were more likely to decline LCS and Black and Hispanic veterans were more likely to accept it. Variation in LCS decisions was accounted for more by the facility and physician offering LCS than by patient factors. These findings suggest that shared decision-making conversations in which patients play a central role in guiding care may enhance patient-centered care and address disparities in LCS.

Stakeholder Research Priorities to Promote Implementation of Shared Decision-Making for Lung Cancer Screening: An American Thoracic Society and Veterans Affairs Health Services Research and Development Statement.

Rationale: Shared decision-making (SDM) for lung cancer screening (LCS) is recommended in guidelines and required by Medicare, yet it is seldom achieved in practice. The best approach for implementing SDM for LCS remains unknown, and the 2021 U.S. Preventive Services Task Force calls for implementation research to increase uptake of SDM for LCS. Objectives: To develop a stakeholder-prioritized research agenda and recommended outcomes to advance implementation of SDM for LCS. Methods: The American Thoracic Society and VA Health Services Research and Development Service convened a multistakeholder committee with expertise in SDM, LCS, patient-centered care, and implementation science. During a virtual State of the Art conference, we reviewed evidence and identified research questions to address barriers to implementing SDM for LCS, as well as outcome constructs, which were refined by writing group members. Our committee (n = 34) then ranked research questions and SDM effectiveness outcomes by perceived importance in an online survey. Results: We present our committee's consensus on three topics important to implementing SDM for LCS: 1) foundational principles for the best practice of SDM for LCS; 2) stakeholder rankings of 22 implementation research questions; and 3) recommended outcomes, including Proctor's implementation outcomes and stakeholder rankings of SDM effectiveness outcomes for hybrid implementation-effectiveness studies. Our committee ranked questions that apply innovative implementation approaches to relieve primary care providers of the sole responsibility of SDM for LCS as highest priority. We rated effectiveness constructs that capture the patient experience of SDM as most important. Conclusions: This statement offers a stakeholder-prioritized research agenda and outcomes to advance implementation of SDM for LCS.

Access to Lung Cancer Screening in the Veterans Health Administration: Does Geographic Distribution Match Need in the Population?

BACKGROUND: Studies show uneven access to Medicare-approved lung cancer screening (LCS) programs across the United States. The Veterans Health Administration (VA), the largest national US integrated health system, is potentially well positioned to coordinate LCS services across regional units to ensure that access matches distribution of need nationally. RESEARCH QUESTION: To what extent does LCS access (considering both VA and partner sites) and use match the distribution of eligible Veterans at state and regional levels? METHODS: In this retrospective analysis, we identified LCS examinations in VA facilities between 2013 and 2019 from the VA Corporate Data Warehouse and plotted VA facilities with LCS geographically. We compared estimated LCS rates (unique Veterans screened per LCS-eligible population) across states and VA regional units. Finally, we assessed whether the VA's new partnership with the GO2 Foundation for Lung Cancer (which includes more than 750 LCS centers) closes geographic gaps in LCS access. RESULTS: We identified 71,898 LCS examinations in 96 of 139 (69.1%) VA facilities in 44 states between 2013 and 2019, with substantial variation across states (0-8 VA LCS facilities per state). Screening rates among eligible Veterans in the population varied more than 30-fold across regional networks (rate ratio, 33.6; 95% CI, 30.8-36.7 for VA New England vs Veterans Integrated Service Network 4), with weak correlation between eligible populations and LCS rates (coefficient, -0.30). Partnering with the GO2 Foundation for Lung Cancer expands capacity and access (eg, all states now have ≥ 1 VA or partner LCS site), but 9 of the 12 states with the highest proportions of rural Veterans still have ≤ 3 total LCS facilities. INTERPRETATION: Disparities in LCS access exist based on where Veterans live, particularly for rural Veterans, even after partnering with the GO2 Foundation for Lung Cancer. The nationally integrated VA system has an opportunity to leverage regional resources to distribute and coordinate LCS services better to ensure equitable access.

Lung Cancer Screening Knowledge, Perceptions, and Decision Making Among African Americans in Detroit, Michigan.

INTRODUCTION: Previously, a web-based, patient-facing decision aid for lung cancer screening, shouldiscreen.com, was developed and evaluated. An initial evaluation was completed before the Medicare coverage decision and recruited a nondiverse sample of mostly former smokers, limiting the understanding of the potential effectiveness of the tool among diverse populations. This study evaluates shouldiscreen.com among African Americans in Metro Detroit. METHODS: Using insights obtained from participatory workshops in this population, content changes to shouldiscreen.com were implemented, and this modified version was evaluated with a before-after study. Measures included knowledge of lung cancer screening, decisional conflict, and concordance between individual preference and screening eligibility. Surveys occurred between April and July 2018. Participants were contacted 6 months after the survey to assess subsequent screening behaviors. Analysis took place in 2019. RESULTS: Data were collected from 74 participants aged 45-77 years, who were current/former smokers with no history of lung cancer. The average knowledge score increased by 25% from 5.7 (SD=1.94) before to 7.1 (SD=2.30) after (out of 13 points). Decisional conflict was halved between before and after. Concordance between individual preference and eligibility for screening increased from 22% (SD=41) to 35% (SD=47). Half of the participants felt uncomfortable answering surveys electronically and requested paper versions. CONCLUSIONS: The use of the tool led to small improvements in lung cancer screening knowledge and increased concordance with current recommendations. Additional design modifications and modes of information delivery of these decision aids should be considered to increase their efficacy in helping populations with lower educational attainment and computer literacy.

Much to do with nothing: microsimulation study on time management in primary care.

OBJECTIVE: To investigate the credibility of claims that general practitioners lack time for shared decision making and preventive care. DESIGN: Monte Carlo microsimulation study. SETTING: Primary care, United States. PARTICIPANTS: Sample of general practitioners (n=1000) representative of annual work hours and patient panel size (n=2000 patients) in the US, derived from the National Health and Nutrition Examination Survey. MAIN OUTCOME MEASURES: The primary outcome was the time needed to deliver shared decision making for highly recommended preventive interventions in relation to time available for preventive care-the prevention-time-space-deficit (ie, time-space needed by doctor exceeding the time-space available). RESULTS: On average, general practitioners have 29 minutes each workday to discuss preventive care services (just over two minutes for each clinic visit) with patients, but they need about 6.1 hours to complete shared decision making for preventive care. 100% of the study sample experienced a prevention-time-space-deficit (mean deficit 5.6 h/day) even given conservative (ie, absurdly wishful) time estimates for shared decision making. However, this time deficit could be easily overcome by reducing personal time and shifting gains to work tasks. For example, general practitioners could reduce the frequency of bathroom breaks to every other day and skip time with older children who don't like them much anyway. CONCLUSIONS: This study confirms a widely held suspicion that general practitioners waste valuable time on "personal care" activities. Primary care overlords, once informed about the extent of this vast reservoir of personal time, can start testing methods to "persuade" general practitioners to reallocate more personal time toward bulging clinical demands.

Identifying Patients for Whom Lung Cancer Screening Is Preference-Sensitive: A Microsimulation Study.

Background: Many health systems are exploring how to implement low-dose computed tomography (LDCT) screening programs that are effective and patient-centered. Objective: To examine factors that influence when LDCT screening is preference-sensitive. Design: State-transition microsimulation model. Data Sources: Two large randomized trials, published decision analyses, and the SEER (Surveillance, Epidemiology, and End Results) cancer registry. Target Population: U.S.-representative sample of simulated patients meeting current U.S. Preventive Services Task Force criteria for screening eligibility. Time Horizon: Lifetime. Perspective: Individual. Intervention: LDCT screening annually for 3 years. Outcome Measures: Lifetime quality-adjusted life-year gains and reduction in lung cancer mortality. To examine the effect of preferences on net benefit, disutilities (the "degree of dislike") quantifying the burden of screening and follow-up were varied across a likely range. The effect of varying the rate of false-positive screening results and overdiagnosis associated with screening was also examined. Results of Base-Case Analysis: Moderate differences in preferences about the downsides of LDCT screening influenced whether screening was appropriate for eligible persons with annual lung cancer risk less than 0.3% or life expectancy less than 10.5 years. For higher-risk eligible persons with longer life expectancy (roughly 50% of the study population), the benefits of LDCT screening overcame even highly negative views about screening and its downsides. Results of Sensitivity Analysis: Rates of false-positive findings and overdiagnosed lung cancer were not highly influential. Limitation: The quantitative thresholds that were identified may vary depending on the structure of the microsimulation model. Conclusion: Identifying circumstances in which LDCT screening is more versus less preference-sensitive may help clinicians personalize their screening discussions, tailoring to both preferences and clinical benefit. Primary Funding Source: None.

Episodic oral antibiotic use in CF: Discordance between the electronic medical record and self-report.

BACKGROUND: Accurate accounting of antibiotic use is necessary for studies comparing the CF airway microbiota across clinically relevant disease states. While poor adherence to chronic therapies is well described for individuals with CF, use patterns of episodic oral antibiotics are less clear. METHODS: Eleven individuals with CF completed daily questionnaires regarding antibiotic use for a mean of 458days. Self-report of episodic oral antibiotic use was compared to antibiotic prescription data in the electronic medical record (EMR). RESULTS: Self-reported use of episodic oral antibiotics differed from EMR data an average of 8.3% of days per subject. The majority of these discrepancies were due to self-reported use of oral antibiotics outside of the EMR-documented dates of antibiotic prescription. CONCLUSIONS: Discrepancies exist between self-reported use of episodic oral antibiotics and EMR data that have implications for studies of the CF airway microbiota.

Doctors and numbers: an assessment of the critical risk interpretation test.

BACKGROUND: Risk interpretation affects decision making. Yet, there is no valid assessment of how clinicians interpret the risk data that they commonly encounter. OBJECTIVE: To establish the reliability and validity of a 20-item test of clinicians' risk interpretation. METHODS: The Critical Risk Interpretation Test (CRIT) measures clinicians' abilities to 1) modify the interpretation based on meaningful differences in the outcome (e.g., disease specific v. all-cause mortality) and time period (e.g., lifetime v. 10-year mortality), 2) maintain a stable interpretation for different risk framings (e.g., relative v. absolute risk), and 3) correctly interpret how diagnostic testing modifies risk. There were 658 clinicians and medical trainees who participated: 116 nurse practitioners (NPs) at a national conference, 273 medical students at 1 institution, 148 residents in internal medicine at 2 institutions, and 121 internists at 1 institution. Participants completed a self-administered paper test during educational conferences. Seventeen evidence-based medicine experts took the test online and formally assessed content validity. Eighteen second-year medical students were recruited to take the test and a retest 3 weeks later to explore test-retest correlation. RESULTS: Expert review supported test clarity and content validity. Factor analysis supported that the CRIT identifies at least 3 separable areas of clinician knowledge. Test-retest correlation was fair (intraclass correlation coefficient = 0.65; standard error = 0.15). Scores on our test correlated with other tests of related abilities. Mean test scores varied among groups, with differences in prior evidence-based medicine training and experience (93 for NPs, 101 for medical students, 101 for residents, 103 for academic internists, and 110 for physician experts; P < 0.001). CONCLUSIONS: Our results provide supporting evidence for the reliability and validity of the CRIT as an index of critical risk interpretation abilities, which is acceptable and feasible to administer in an educational setting.