Half a Century of Wilson & Jungner: Reflections on the Governance of Population Screening.

Background: In their landmark report on the "Principles and Practice of Screening for Disease" (1968), Wilson and Jungner noted that the practice of screening is just as important for securing beneficial outcomes and avoiding harms as the formulation of principles. Many jurisdictions have since established various kinds of "screening governance organizations" to provide oversight of screening practice. Yet to date there has been relatively little reflection on the nature and organization of screening governance itself, or on how different governance arrangements affect the way screening is implemented and perceived and the balance of benefits and harms it delivers. Methods: An international expert policy workshop convened by Sturdy, Miller and Hogarth. Results: While effective governance is essential to promote beneficial screening practices and avoid attendant harms, screening governance organizations face enduring challenges. These challenges are social and ethical as much as technical. Evidence-based adjudication of the benefits and harms of population screening must take account of factors that inform the production and interpretation of evidence, including the divergent professional, financial and personal commitments of stakeholders. Similarly, when planning and overseeing organized screening programs, screening governance organizations must persuade or compel multiple stakeholders to work together to a common end. Screening governance organizations in different jurisdictions vary widely in how they are constituted, how they relate to other interested organizations and actors, and what powers and authority they wield. Yet we know little about how these differences affect the way screening is implemented, and with what consequences. Conclusions: Systematic research into how screening governance is organized in different jurisdictions would facilitate policy learning to address enduring challenges. Even without such research, informal exchange and sharing of experiences between screening governance organizations can deliver invaluable insights into the social as well as the technical aspects of governance.

Results From a Trial of an Online Diabetes Prevention Program Intervention.

INTRODUCTION: Online Diabetes Prevention Programs (DPPs) can be scaled up and delivered broadly. However, little is known about real-world effectiveness and how outcomes compare with in-person DPP. This study examined online DPP weight loss and participation outcomes and secondarily compared outcomes among participating individuals with parallel in-person interventions. STUDY DESIGN: A large non-randomized trial supplemented by a comparative analysis of participating individuals from a concurrent trial of two parallel in-person programs: in-person DPP and the Veterans Administration's standard of care weight loss program (MOVE!). SETTING/PARTICIPANTS: Obese/overweight Veterans with prediabetes enrolled in online DPP (n = 268) between 2013 and 2014. Similar eligibility criteria were used to enroll in-person participants between 2012 and 2014 (n = 273 in-person DPP, n = 114 MOVE!) within a separate trial. INTERVENTION: Online DPP included a virtual group format, live e-coach, weekly modules delivered asynchronously, and wireless home scales. In-person programs included eight to 22 group-based, face-to-face sessions. MAIN OUTCOMES MEASURES: Weight change at 6 and 12 months using wirelessly uploaded home scale data or electronic medical record weights from clinical in-person visits. Outcomes were analyzed between 2015 and 2017. RESULTS: From 1,182 invitations, 268 (23%) participants enrolled in online DPP. Among these, 158 (56%) completed eight or more modules; mean weight change was -4.7kg at 6 months and -4.0kg at 12 months. In a supplemental analysis of participants completing one or more sessions/modules, online DPP participants were most likely to complete eight or more sessions/modules (87% online DPP vs 59% in-person DPP vs 55% MOVE!, p < 0.001). Online and in-person DPP participants lost significantly more weight than MOVE! participants at 6 and 12 months; there was no significant difference in weight change between online and in-person DPP. CONCLUSIONS: An intensive, multifaceted online DPP intervention had higher participation but similar weight loss compared to in-person DPP. An intensive, multifaceted online DPP intervention may be as effective as in-person DPP and help expand reach to those at risk.

Screening for Lung Cancer: CHEST Guideline and Expert Panel Report.

BACKGROUND: Low-dose chest CT screening for lung cancer has become a standard of care in the United States in the past few years, in large part due to the results of the National Lung Screening Trial. The benefit and harms of low-dose chest CT screening differ in both frequency and magnitude. The translation of a favorable balance of benefit and harms into practice can be difficult. Here, we update the evidence base for the benefit, harms, and implementation of low radiation dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not. METHODS: Approved panelists developed key questions using the PICO (population, intervention, comparator, and outcome) format to address the benefit and harms of low-dose CT screening, as well as key areas of program implementation. A systematic literature review was conducted by using MEDLINE via PubMed, Embase, and the Cochrane Library. Reference lists from relevant retrievals were searched, and additional papers were added. The quality of the evidence was assessed for each critical or important outcome of interest using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and ungraded statements were drafted, voted on, and revised until consensus was reached. RESULTS: The systematic literature review identified 59 studies that informed the response to the 12 PICO questions that were developed. Key clinical questions were addressed resulting in six graded recommendations and nine ungraded consensus based statements. CONCLUSIONS: Evidence suggests that low-dose CT screening for lung cancer results in a favorable but tenuous balance of benefit and harms. The selection of screen-eligible patients, the quality of imaging and image interpretation, the management of screen-detected findings, and the effectiveness of smoking cessation interventions can affect this balance. Additional research is needed to optimize the approach to low-dose CT screening.

Practical partnered research to improve weight loss among overweight/obese veterans: lessons from the trenches.

BACKGROUND: Obesity and obesity-related conditions, such as type 2 diabetes, are a major issue for Veteran health. Veterans Health Administration (VA) researchers and health systems leaders have worked separately and together to provide more effective weight management programs for Veterans. Although randomized clinical trials are often considered the gold standard for establishing efficacy of interventions in controlled circumstances, pragmatic clinical trials (PCTs) provide agility for translation. MAIN TEXT: VA researchers and health system leaders collaboratively designed a PCT to compare the Diabetes Prevention Program (VA-DPP) to usual care (MOVE!®) in promoting weight loss and glycemic control among overweight/obese Veterans with prediabetes. Together, they navigated the tensions that exist between quality improvement and research activities, facing challenges but reaping significant rewards. Early findings led to updated national guidance for delivering obesity treatment in VA. SHORT CONCLUSION: Partnered research and the use of PCTs can be powerful strategies for accelerating evidence-based findings into practice. Collaborative partnerships between researchers and health systems leaders can help enhance and sustain translation in real-world settings.

Diabetes Prevention Program Translation in the Veterans Health Administration.

INTRODUCTION: This clinical demonstration trial compared the effectiveness of the Veterans Affairs Diabetes Prevention Program (VA-DPP) with an evidence-based usual care weight management program (MOVE!®) in the Veterans Health Administration health system. DESIGN: Prospective, pragmatic, non-randomized comparative effectiveness study of two behavioral weight management interventions. SETTING/PARTICIPANTS: Obese/overweight Veterans with prediabetes were recruited from three geographically diverse VA sites between 2012 and 2014. INTERVENTION: VA-DPP included 22 group-based intensive lifestyle change sessions. MAIN OUTCOME MEASURES: Weight change at 6 and 12 months, hemoglobin A1c (HbA1c) at 12 months, and VA health expenditure changes at 15 months were assessed using VA electronic health record and claims data. Between- and within-group comparisons for weight and HbA1c were done using linear mixed-effects models controlling for age, gender, race/ethnicity, baseline outcome values, and site. Analyses were conducted in 2015-2016. RESULTS: A total of 387 participants enrolled (273 VA-DPP, 114 MOVE!). More VA-DPP participants completed at least one (73.3% VA-DPP vs 57.5% MOVE! p=0.002); four (57.5% VA-DPP vs 42.5% MOVE!, p=0.007); and eight or more sessions (42.5% VA-DPP vs 31% MOVE!, p=0.035). Weight loss from baseline was significant at both 6 (p<0.001) and 12 months (p<0.001) for VA-DPP participants, but only significant at 6 months for MOVE! participants (p=0.004). Between groups, there were significant differences in 6-month weight loss (-4.1 kg VA-DPP vs -1.9 kg MOVE!, p<0.001), but not 12-month weight loss (-3.4 kg VA-DPP vs -2.0 kg MOVE!, p=0.16). There were no significant differences in HbA1c change or outpatient, inpatient, and total VA expenditures. CONCLUSIONS: VA-DPP participants had higher participation rates and weight loss at 6 months, but similar weight, HbA1c, and health expenditures at 12 months compared to MOVE! PARTICIPANTS: Features of VA-DPP may help enhance the capability of MOVE! to reach a larger proportion of the served population and promote individual-level weight maintenance.

Implementation of Lung Cancer Screening in the Veterans Health Administration.

Importance: The US Preventive Services Task Force recommends annual lung cancer screening (LCS) with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years. There is little published experience regarding implementing this recommendation in clinical practice. Objectives: To describe organizational- and patient-level experiences with implementing an LCS program in selected Veterans Health Administration (VHA) hospitals and to estimate the number of VHA patients who may be candidates for LCS. Design, Setting, and Participants: This clinical demonstration project was conducted at 8 academic VHA hospitals among 93 033 primary care patients who were assessed on screening criteria; 2106 patients underwent LCS between July 1, 2013, and June 30, 2015. Interventions: Implementation Guide and support, full-time LCS coordinators, electronic tools, tracking database, patient education materials, and radiologic and nodule follow-up guidelines. Main Outcomes and Measures: Description of implementation processes; percentages of patients who agreed to undergo LCS, had positive findings on results of low-dose computed tomographic scans (nodules to be tracked or suspicious findings), were found to have lung cancer, or had incidental findings; and estimated number of VHA patients who met the criteria for LCS. Results: Of the 4246 patients who met the criteria for LCS, 2452 (57.7%) agreed to undergo screening and 2106 (2028 men and 78 women; mean [SD] age, 64.9 [5.1] years) underwent LCS. Wide variation in processes and patient experiences occurred among the 8 sites. Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer. A variety of incidental findings, such as emphysema, other pulmonary abnormalities, and coronary artery calcification, were noted on the scans of 857 patients (40.7%). Conclusions and Relevance: It is estimated that nearly 900 000 of a population of 6.7 million VHA patients met the criteria for LCS. Implementation of LCS in the VHA will likely lead to large numbers of patients eligible for LCS and will require substantial clinical effort for both patients and staff.

Developing and Testing an Electronic Measure of Screening Colonoscopy Overuse in a Large Integrated Healthcare System.

BACKGROUND: Most existing performance measures focus on underuse of care, but there is growing interest in identifying and reducing overuse. OBJECTIVE: We aimed to develop a valid and reliable electronic performance measure of overuse of screening colonoscopy in the Veterans Affairs Health Care System (VA), and to quantify overuse in VA. DESIGN: This was a cross-sectional study with multiple cross-sections. SUBJECTS: U.S. Veterans who underwent screening colonoscopy between 2011 and 2013. MAIN MEASURES: Overuse of screening colonoscopy, using a validated electronic measure developed by an expert workgroup. KEY RESULTS: Compared to results obtained from manual record review, the electronic measure was highly specific (97 %) for overuse, but not sensitive (20 %). After exclusion of diagnostic and high-risk screening or surveillance procedures, the validated electronic measure identified 88,754 average-risk screening colonoscopies performed in VA during 2013. Of these, 20,530 (23 %) met the definition for probable (17 %) or possible (6 %) overuse. Substantial variation in colonoscopy overuse was noted between Veterans Integrated Care Networks (VISNs) and between facilities, with a nearly twofold difference between the maximum and minimum rates of overuse at the VISN level and a nearly eightfold difference at the facility level. Overuse at the VISN and facility level was relatively stable over time. CONCLUSIONS: Overuse of screening colonoscopy can be measured reliably and with high specificity using electronic data, and is common in a large integrated healthcare system. Overuse measures, such as those we have specified through a consensus workgroup process, could be combined with underuse measures to improve the appropriateness of colorectal cancer screening.

Implementation of a prediabetes identification algorithm for overweight and obese Veterans.

Type 2 diabetes prevention is an important national goal for the Veteran Health Administration (VHA): one in four Veterans has diabetes. We implemented a prediabetes identification algorithm to estimate prediabetes prevalence among overweight and obese Veterans at Department of Veterans Affairs (VA) medical centers (VAMCs) in preparation for the launch of a pragmatic study of Diabetes Prevention Program (DPP) delivery to Veterans with prediabetes. This project was embedded within the VA DPP Clinical Demonstration Project conducted in 2012 to 2015. Veterans who attended orientation sessions for an established VHA weight-loss program (MOVE!) were recruited from VAMCs with geographically and racially diverse populations using existing referral processes. Each site implemented and adapted the prediabetes identification algorithm to best fit their local clinical context. Sites relied on an existing referral process in which a prediabetes identification algorithm was implemented in parallel with existing clinical flow; this approach limited the number of overweight and obese Veterans who were assessed and screened. We evaluated 1,830 patients through chart reviews, interviews, and/or laboratory tests. In this cohort, our estimated prevalence rates for normal glycemic status, prediabetes, and diabetes were 29% (n = 530), 28% (n = 504), and 43% (n = 796), respectively. Implementation of targeted prediabetes identification programs requires careful consideration of how prediabetes assessment and screening will occur.

A National Survey of Pulmonologists' Views on Low-Dose Computed Tomography Screening for Lung Cancer.

RATIONALE: Multiple guidelines now recommend low-dose computed tomography (LDCT) screening for lung cancer. Given their central role in the planning of LDCT screening programs, pulmonologists' beliefs about LDCT screening will affect the safety, cost-effectiveness, and success of LDCT screening implementation. OBJECTIVES: To assess pulmonologists' propensity to offer lung cancer screening and their perceptions about LDCT screening. METHODS: We performed a national web-based survey, administered July 2013 to February 2014, among all staff pulmonologists active in Veterans Health Administration pulmonary clinics. The primary outcome was screening propensity (on the basis of responses to clinical vignettes) in relation to guidelines. Using bivariate and multinomial logistic regression, we assessed how perceptions of the evidence, trade-offs, and barriers to implementation of LDCT screening programs affected propensity to screen. MEASUREMENTS AND MAIN RESULTS: Of 573 eligible pulmonologists e-mailed, 286 (49.9%) participated. Approximately one-half (52.4%) had a propensity for guideline-concordant screening, 22.7% for overscreening, and 24.9% for underscreening. In bivariate analyses, guideline concordance was associated with acceptance of trial evidence, guidelines, and the efficacy of screening. In multivariable models, underscreeners were more likely to cite the potential harms of screening (e.g., false-positive findings, radiation exposure, incidental findings, unfavorable cost-benefit ratio), as influential factors (relative risk, 3.9; 95% confidence interval, 1.5-9.67) and were less influenced by trial evidence and guidelines (relative risk, 0.06; 95% confidence interval, 0.02-0.2), as compared with guideline-concordant screeners. Local resource availability did not significantly affect screening propensity, but insufficient infrastructure and personnel were commonly perceived barriers to implementation. CONCLUSIONS: Pulmonologists have varied perceptions of the evidence and trade-offs of LDCT screening, leading to the potential for over- and underscreening. To minimize potential harms as LDCT screening is widely implemented, physicians must understand which patients are appropriate candidates and engage those patients in a shared decision-making process regarding the trade-offs of LDCT screening.

Disease Prevention in the Veterans Health Administration.

The burden of chronic diseases is substantial among veterans who are seen in the Veterans Health Administration (VHA) health care system. Healthy lifestyle interventions and clinical preventive services can help veterans improve their health and well-being. The VHA's National Center for Health Promotion and Disease Prevention supports policies, programs, resources, and training for VHA.

Implementation of new clinical programs in the VHA healthcare system: the importance of early collaboration between clinical leadership and research.

Collaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.

Training veterans to provide peer support in a weight-management program: MOVE!

INTRODUCTION: The Veterans Health Administration (VHA) has implemented MOVE!, a weight-management program for veterans designed to address the increasing proportion of overweight and obese veterans. The objective of our study was to determine whether peer support employing motivational interviewing (MI) could positively influence lifestyle changes, thus expanding the reach of the MOVE! program. We describe the initial evaluation of the peer training program. METHODS: We developed an MI peer ounselor training program for volunteer veterans, the "Buddies" program, to provide one-on-one telephone support for veterans enrolled in MOVE!. Buddies were recruited at 5 VHA sites and trained to provide peer support for the 6-month MOVE! intervention. We used a DVD to teach MI skills and followed with 2 to 3 booster sessions. We observed training, conducted pre- and posttraining surveys, and debriefed focus groups to assess training feasibility. RESULTS: Fifty-six Buddies were trained. Results indicate positive receipt of the program (89% reported learning about peer counseling and 87% reported learning communication skills). Buddies showed a small improvement in MI self-efficacy on posttraining surveys. We also identified key challenges to learning MI and training implementation. CONCLUSIONS: MI training is feasible to implement and acceptable to volunteer Buddies. Trainers must assess how effectively volunteers learn MI skills in order to enhance its effective use in health promotion.

Colorectal cancer testing in the national Veterans Health Administration.

BACKGROUND: Colorectal cancer (CRC) screening is a priority for the Veteran's Health Administration (VHA). Optimizing fecal occult blood testing (FOBT) is integral to CRC screening in health care systems. AIMS: The purpose of this study was to characterize the utilization of CRC testing in a large integrated health care system (VHA), determine current rates of CRC testing by FOBT and examine factors associated with lack of FOBT card return. METHODS: The VHA Office of Quality and Performance (OQP) collected data from a national sample of Veterans from October 2008 to September 2009. Rates and modality of CRC testing for eligible Veterans were calculated. Among those offered FOBT, bivariate analyses were performed to describe population characteristics by FOBT return. Logistic regression was used to determine factors independently associated with lack of FOBT return. RESULTS: A total of 36,336 Veterans were included. On weighted analysis, 80.4% of Veterans received a form of CRC screening. The majority underwent colonoscopy in the prior 10 years (71.6%), followed by FOBT in the prior year (24.0%). A total of 31.0% did not return FOBT cards that were provided. Factors associated with a lack of FOBT return included: younger age, female gender, non-Caucasian race, living in the Northeast, current smoking and lack of influenza vaccination. CONCLUSIONS: Overall rates of CRC screening in VHA are high. Systems-based practices within VHA likely play a role in successful CRC screening. CRC screening is most often via colonoscopy, followed by FOBT. Characteristics associated with non-adherence with FOBT may inform future quality improvement initiatives in health care systems.