Clinician Perspectives on Factors Affecting Shared Decision Making about Lung Cancer Screening

Background/Objective. In 2015, the Centers for Medicare and Medicaid Services (CMS) announced coverage for annual lung cancer screening (LCS) with low dose computed tomography (LDCT) for individuals who are 55 to 77 years of age, have \u3e 30 pack years of smoking history, and undergo shared decision making (SDM) prior to screening. Most referrals for LCS are initiated in primary care. Currently, little is known about how primary care physicians view SDM and barriers in practice to SDM about LCS. This study aimed to gather information to help fill these knowledge gaps. Methods. I worked with senior leadership in the Department of Medicine to identify a set of internal medicine physicians at Thomas Jefferson University (TJU) and contacted them via email requesting their participation in an interview about SDM in LCS. I developed an interview guide that included questions about the following: understanding of SDM, perceptions about SDM in LCS, and receptivity to use of an online decision support intervention (DSI). I completed in-person, audio recorded interviews, which were transcribed for analysis. I then analyzed the interview transcripts using NVivo qualitative analysis software. Results. Nine physicians were interviewed from a pool of twenty-three physicians over a period of three weeks. With regards to understanding of SDM, physicians were in agreement that SDM is a joint decision based on a discussion about the risks and benefits of an intervention that considers patient values and medical status. Physician perceptions of SDM in LCS was influenced by patient comorbidities, LCS controversies and complexity, and limited office time. Receptivity to using an online DSI was generally positive and particularly favored its patient education component and easing of physician workload. Conclusions. Observations from this study highlight a common general understanding of SDM, yet mixed approaches to SDM in LCS. Strong support also exists for a DSI that educates patients about LCS and saves physicians time. Future steps include interviewing a set of family medicine physicians to investigate potential differences in viewpoints compared to internal medicine physicians

Increasing Colorectal Cancer Screening Among Hispanic Primary Care Patients: RE-AIM Analysis.

Context: Hispanic adults experience disparities in rates of colorectal cancer (CRC) screening. This RE-AIM analysis encompassed a multilevel decision support and navigation intervention (DSNI) for CRC screening. Interim findings were previously presented; we now aim to share the final analysis, particularly for effectiveness and implementation. Objective: Apply RE-AIM framework to a completed randomized controlled trial of a CRC screening intervention for Hispanic adults Setting: Five primary care practices Patients or Other Participants: Potential participants included a sampling frame of 2,720 screening-eligible patients, ages 50-75, Hispanic ethnicity, without history of CRC and polyps. 400 participants were enrolled. Intervention/Instrument: Decision support and navigation by a bilingual Patient Assistant (PA) as compared to a standard mailed intervention (SI) Main and Secondary Outcome Measures: 1) Reach- Study participants as compared to sampling frame 2) Effectiveness- Screening adherence 3) Adoption- Number of practice participants to complete intervention, engagement of patient and stakeholder advisory committee (PASAC) 4) Implementation- Quantitative data pertaining to patient contacts and communication of screening plan to primary care practices, Qualitative data on PA and Telephone Interviewer (TI) experiences 5) Maintenance- Health system dissemination (Pending). Results: 1) Reach- Study participants differed from the sampling frame in that ages 50-59 were overrepresented. There were no differences in race, gender, or language. 2) Effectiveness- Screening adherence was significantly increased in the DSNI group (73%) as compared to the SI group (44%) (OR=3.48, CI: 2.29-4.29,

Identifying and Mapping Barriers and Facilitators to Urban Trial Use: A Qualitative Geographic Information Systems Study

Introduction: Urban green spaces, including urban trails, have demonstrated health benefits to those who utilize these spaces. However, access and use of these spaces are impacted by many different individual and community-level factors. This dissertation examined barriers and facilitators to urban trail use within two neighborhoods along the Schuylkill Banks in Philadelphia, Pennsylvania. Methods: In each of the two neighborhoods, disorder audits were conducted. Freelisting was also conducted with those actively using the trail and among those encountered in the neighborhood. Finally, Geographic Information Systems (GIS) were used to create composite maps using secondary data representing terms identified during freelisting, providing a visualization of areas with varying facilitators to trail use. Results: Neighborhood audits demonstrated substantially higher disorder in the blocks around one access point as compared to the other. Freelisting responses from 233 participants revealed the primary factors that facilitated trail use to be convenience and access. Infrequent users highlighted factors such as available transportation and parking, while frequent users emphasized the importance of access related issues, such as having a ramp at the access point entrance. Composite maps created with GIS showed that, areas closer to the trail points indicated greater ease of trail use, however, this ease of use was not consistent along the entire trail. Maps representing freelisting terms reported by infrequent users showed that areas with more facilitators were scattered, with each high facilitator segment covering a small geographical area. Conclusion: Organizational stakeholders can use results from this dissertation to begin community discussions about trail use and access, especially in communities around the access points. Additionally, maps derived from this dissertation can be used for identification and prioritization of communities with limited facilitators to trail use. Ultimately, this methodology has the potential to impact practice and policy, locally in Philadelphia and more broadly, and improve the planning and implementation of future urban trails