Clinician Views of Proactive Tobacco Treatment Programs: A Qualitative Evaluation.

INTRODUCTION: Proactive tobacco treatment programs are an evidence-based strategy to recruit patients who smoke to make supported quit attempts. However, such programs are rarely implemented. We performed a qualitative assessment of clinicians to inform the creation of a proactive outreach program for patients with chronic obstructive pulmonary disease (COPD) who smoke. METHODS: Informed by the Consolidated Framework for Implementation Research, we conducted semi-structured interviews to assess clinician views of proactive outreach, including barriers, program structure, and the use of technology. Clinicians included primary and specialty care physicians, nurses and advanced practice providers, pharmacists, respiratory therapists, a psychologist, and relevant members of leadership. Interviews were transcribed and analyzed using directed content analysis. RESULTS: Clinicians in all roles identified that proactive outreach could be an effective use of resources to help patients with COPD who smoke quit with several advantages over the current state. Clinicians disagreed on the priority population (e.g., younger patients, sicker patients), and to some extent on whether proactive outreach is a clinical priority. Though they supported that technology could be part of the outreach program, most advocated for multiple avenues (phone calls, drop-in clinic, texting), as these patients were perceived to be low technology utilizers. The primary implementation barriers were competing priorities and cost, as well as unclear billing and staffing models. CONCLUSIONS: Clinicians support proactive outreach for patients with COPD, but the optimal way to structure, staff, and fund such programs remains unclear. Health systems should leverage implementation strategies to speed uptake of these potentially life-saving programs.

Association of patient and health care organization factors with incidental nodule guidelines adherence: A multi-system observational study.

BACKGROUND: Health care organizations are increasingly developing systems to ensure patients with pulmonary nodules receive guideline-adherent care. Our goal was to determine patient and organization factors that are associated with radiologist adherence as well as clinician and patient concordance to 2005 Fleischner Society guidelines for incidental pulmonary nodule follow-up. MATERIALS: Trained researchers abstracted data from the electronic health record from two Veterans Affairs health care systems for patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. METHODS: We classified radiology reports and patient follow-up into two categories. Radiologist-Fleischner Adherence was the agreement between the radiologist's recommendation in the computed tomography report and the 2005 Fleischner Society guidelines. Clinician/Patient-Fleischner Concordance was agreement between patient follow-up and the guidelines. We calculated multivariable-adjusted predicted probabilities for factors associated with Radiologist-Fleischner Adherence and Clinician/Patient-Fleischner Concordance. RESULTS: Among 3150 patients, 69% of radiologist recommendations were adherent to 2005 Fleischner guidelines, 4% were more aggressive, and 27% recommended less aggressive follow-up. Overall, only 48% of patients underwent follow-up concordant with 2005 Fleischner Society guidelines, 37% had less aggressive follow-up, and 15% had more aggressive follow-up. Radiologist-Fleischner Adherence was associated with Clinician/Patient-Fleischner Concordance with evidence for effect modification by health care system. CONCLUSION: Clinicians and patients seem to follow radiologists' recommendations but often do not obtain concordant follow-up, likely due to downstream differential processes in each health care system. Health care organizations need to develop comprehensive and rigorous tools to ensure high levels of appropriate follow-up for patients with pulmonary nodules.

Longitudinal Assessment of Communication with Patient-Reported Outcomes During Lung Cancer Screening.

BACKGROUND: Many organizations recommend clinicians use structured communication processes, referred to as "shared decision making," to improve patient-reported outcomes for patients considering lung cancer screening (LCS). RESEARCH QUESTION: Which components of high-quality patient-centered communication are associated with decision regret and distress? STUDY DESIGN AND METHODS: We conducted a prospective, longitudinal, repeated measures, cohort study among patients undergoing lung cancer screening in three different healthcare systems. We surveyed participants using validated measures of decision regret, decision satisfaction, distress, and patient-clinician communication domains up to a year after the low-dose computed tomography (LDCT) for LCS. For longitudinal analyses, we applied a series of generalized estimating equations to measure the association of the "patient as person" communication domain, screening knowledge, and decision concordance with decision regret and distress. RESULTS: When assessed 2-4 weeks after the LDCT, 202 (58.9%) and 8 (2.3%) of 343 total respondents reported mild and moderate/severe decision regret, respectively, while 29 (9.2%) participants of 315 total reported mild distress and 19 (6.0%) moderate or greater distress. The mean ± SD decision satisfaction scores (0 to 10 scale) were 9.82 ± 0.89, 9.08 ± 1.54, and 6.13 ± 3.40 among those with no, mild, and moderate/severe regret respectively. Distress scores remained low after the LDCT, even among those with nodules. Patient-centered communication domains were not associated with decision regret or distress. INTERPRETATION: Patients undergoing LCS rarely experience moderate or greater decision regret and distress. Although many participants reported mild decision regret, most were very satisfied over the year after their LDCT for LCS. Communication processes were not associated with regret and distress, suggesting that it may be challenging for communication interventions to reduce the harms of LCS.

Education for Tobacco Use Disorder Treatment: Current State, Evidence, and Unmet Needs.

Background: Tobacco use is undertreated in the medical setting. One driver may be inadequate tobacco use disorder treatment (TUDT) training for clinicians in specialties treating tobacco-dependent patients. Objective: We sought to evaluate the current state of TUDT training for diverse professionals and how these skills are assessed in credentialing exams. Methods: We performed a focused review of current educational practices, evidence-based strategies, and accreditation exam contents focused on TUDT. Results: Among medical students, participants in reviewed studies reported anywhere from 45 minutes to 3 hours of TUDT training throughout their 4-year programs, most often in the form of didactic sessions. Similarly, little TUDT training was reported at the post-graduate (residency, fellowship, continuing medical education) levels, and reported training was typically delivered as time-based (expected hours of instruction) rather than competency-based (demonstration of mastery) learning. Multiple studies evaluated effective TUDT curricula at varied stages of training. More effective curricula incorporated longitudinal sessions and active learning, such as standardized patient encounters or proctored patient visits. Knowledge of TUDT is minimally evaluated on certification exams. For example, the American Board of Internal Medicine blueprint lists TUDT as <2% of one subtopic on both the internal medicine and pulmonary exams. Conclusion: TUDT training for most clinicians is minimal, does not assess competency, and is minimally evaluated on certification exams. Effective, evidence-based TUDT training incorporating active learning should be integrated into medical education at all levels, with attention paid to inclusion on subsequent certifying exams.