Utilization Of Lung Cancer Screening And Molecular Testing To Improve Lung Cancer Outcomes

Despite progress in detection and treatment, lung cancer remains the leading cause of cancer-related death in the United States. The United States Preventive Services Task Force (USPSTF) recommends adults at high risk for lung cancer undergo annual low-dose computed tomography (LDCT) screening, however, lung cancer screening (LCS) uptake remains low. Qualitative research on family physician (FP) perceptions and experiences with LCS has been limited since USPSTF publication and Centers for Medicare and Medicaid Services (CMS) decision memo. We conducted a qualitative study to assess FP knowledge and perceptions of LCS and gain insight into their current experiences with LDCT. A convenience sample of FPs were asked to participate in Skype audio interviews. A semi-structured interview guide was used to navigate the interviews. A theme codebook was developed using the constant comparison technique. All interviews were coded by two reviewers We found that FP knowledge about the scientific evidence and patient eligibility criteria for LDCT was suboptimal. Age and smoking history were the primary drivers of a FPs decision to discuss LCS. Most FPs knew that they should initiate LDCT discussions with high risk patients, however, they indicated that they would be willing to screen patients outside of the specified criteria. LDCT cost and lack of time were cited as barriers. Facilitators included screening tools in the clinic waiting room and electronic medical record notifications. These results indicate a need for FP education about LCS, as well as tools to assist providers in the clinic. As LCS becomes more widely adopted, more lung cancers will be detected at an earlier stage. While tumor molecular testing (MT) is currently recommended for patients with metastatic disease, MT could increasingly be used in early stage patients to guide initial treatment decisions. Disparities in MT and targeted therapy utilization may exist. We quantitatively evaluated factors related to MT and erlotinib utilization and the impact of these on overall survival (OS). Stage IIIB/IV non-small cell lung cancer (NSCLC) cases diagnosed between January 1, 2002 and December 31, 2012 and available through the South Carolina Central Cancer Registry were linked to SC State Employee Health Plan (SCSEHP) and Medicaid administrative claims data. MT and erlotinib utilization were independently categorized as “yes” or “no” based on claims data. We found several characteristics associated with MT, including younger age, having an out-of-state provider, being diagnosed in 2010 or later, adenocarcinoma histology, and low tumor grade. Risk of death was reduced and OS was longer for patients with MT. Younger age, female sex, SCSHEP insurance, having an out-of-state provider, adenocarcinoma histology, and having molecular testing were associated with erlotinib utilization. Risk of death was lower for patients treated with erlotinib and OS was longer. These results suggest that tumor MT and erlotinib utilization lead to improved patient survival. Additional research should evaluate these important factors in nationally representative datasets

Top 10 health care ethics challenges facing the public: views of Toronto bioethicists

BACKGROUND: There are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds. DISCUSSION: The top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill. SUMMARY: Although many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge

The SISAL database: a global resource to document oxygen and carbon isotope records from speleothems

Stable isotope records from speleothems provide information on past climate changes, most particularly information that can be used to reconstruct past changes in precipitation and atmospheric circulation. These records are increasingly being used to provide “out-of-sample” evaluations of isotope-enabled climate models. SISAL (Speleothem Isotope Synthesis and Analysis) is an international working group of the Past Global Changes (PAGES) project. The working group aims to provide a comprehensive compilation of speleothem isotope records for climate reconstruction and model evaluation. The SISAL database contains data for individual speleothems, grouped by cave system. Stable isotopes of oxygen and carbon (δ 18O, δ 13C) measurements are referenced by distance from the top or bottom of the speleothem. Additional tables provide information on dating, including information on the dates used to construct the original age model and sufficient information to assess the quality of each data set and to erect a standardized chronology across different speleothems. The metadata table provides location information, information on the full range of measurements carried out on each speleothem and information on the cave system that is relevant to the interpretation of the records, as well as citations for both publications and archived data. The compiled data are available at https://doi.org/10.17864/1947.147

Evaluating model outputs using integrated global speleothem records of climate change since the last glacial

Although quantitative isotopic data from speleothems has been used to evaluate isotope-enabled model simulations, currently no consensus exists regarding the most appropriate methodology through which to achieve this. A number of modelling groups will be running isotope-enabled palaeoclimate simulations in the framework of the Coupled Model Intercomparison Project Phase 6, so it is timely to evaluate different approaches to use the speleothem data for data-model comparisons. Here, we illustrate this using 456 globally-distributed speleothem δ18O records from an updated version of the Speleothem Isotopes Synthesis and Analysis (SISAL) database and palaeoclimate simulations generated using the ECHAM5-wiso isotope-enabled atmospheric circulation model. We show that the SISAL records reproduce the first-order spatial patterns of isotopic variability in the modern day, strongly supporting the application of this dataset for evaluating model-derived isotope variability into the past. However, the discontinuous nature of many speleothem records complicates procuring large numbers of records if data-model comparisons are made using the traditional approach of comparing anomalies between a control period and a given palaeoclimate experiment. To circumvent this issue, we illustrate techniques through which the absolute isotopic values during any time period could be used for model evaluation. Specifically, we show that speleothem isotope records allow an assessment of a model’s ability to simulate spatial isotopic trends. Our analyses provide a protocol for using speleothem isotopic data for model evaluation, including screening the observations to take into account the impact of speleothem mineralogy on 18O values, the optimum period for the modern observational baseline, and the selection of an appropriate time-window for creating means of the isotope data for palaeo time slices

Implementing precision medicine programs and clinical trials in the community-based oncology practice: barriers and best practices

There has been a rapid uptick in the pace of oncology precision medicine advancements over the past several decades as a result of increasingly sophisticated technology and the ability to study more patients through innovative trial designs. As more precision oncology approaches are developed, the need for precision medicine trials is increasing in the community setting, where most patients with cancer are treated. However, community-based practices, as well as some academic centers, may face unique barriers to implementing precision medicine programs and trials within their communities. Such challenges include understanding the tissue needs of molecular tests (e.g., tumor, blood), identifying which molecular tests are best used and when tissue should be tested, interpreting the test results and determining actionability, understanding the role of genetic counseling and/or follow-up testing, determining clinical trial eligibility, and assessing patient attitudes and financial concerns. The purpose of this article is to provide guidance to community-based oncology practices currently conducting clinical trials who want to expand their research program to include precision medicine trials. Here, we describe the core components of precision medicine programs and offer best practices for successful implementation of precision medicine trials in community-based practices

Visual process maps to support implementation efforts: a case example

Abstract Background Process mapping is often used in quality improvement work to examine current processes and workflow and to identify areas to intervene to improve quality. Our objective in this paper is to describe process maps as a visual means of understanding modifiable behaviors and activities, in this case example to ensure that goals of care conversations are part of admitting a veteran in long-term care settings. Methods We completed site visits to 6 VA nursing homes and reviewed their current admission processes. We conducted interviews to document behaviors and activities that occur when a veteran is referred to a long-term care setting, during admission, and during mandatory VA reassessments. We created visualizations of the data using process mapping approaches. Process maps for each site were created to document the admission activities for each VA nursing home and were reviewed by the research team to identify consistencies across sites and to identify potential opportunities for implementing goals of care conversations. Results We identified five consistent behaviors that take place when a veteran is referred and admitted in long-term care. These behaviors are assessing, discussing, decision-making, documenting, and re-assessing. Conclusions Based on the process maps, it seems feasible that the LST note and order template could be completed along with other routine assessment processes. However, this will require more robust multi-disciplinary collaboration among both prescribing and non-prescribing health care providers. Completing the LST template during the current admission process would increase the likelihood that the template is completed in a timely manner, potentially alleviate the perceived time burden, and help with the provision of veteran-centered care.http://deepblue.lib.umich.edu/bitstream/2027.42/174078/1/43058_2020_Article_94.pd

Designing clinical practice feedback reports: three steps illustrated in Veterans Health Affairs long-term care facilities and programs

Abstract Background User-centered design (UCD) methods are well-established techniques for creating useful artifacts, but few studies illustrate their application to clinical feedback reports. When used as an implementation strategy, the content of feedback reports depends on a foundational audit process involving performance measures and data, but these important relationships have not been adequately described. Better guidance on UCD methods for designing feedback reports is needed. Our objective is to describe the feedback report design method for refining the content of prototype reports. Methods We propose a three-step feedback report design method (refinement of measures, data, and display). The three steps follow dependencies such that refinement of measures can require changes to data, which in turn may require changes to the display. We believe this method can be used effectively with a broad range of UCD techniques. Results We illustrate the three-step method as used in implementation of goals of care conversations in long-term care settings in the U.S. Veterans Health Administration. Using iterative usability testing, feedback report content evolved over cycles of the three steps. Following the steps in the proposed method through 12 iterations with 13 participants, we improved the usability of the feedback reports. Conclusions UCD methods can improve feedback report content through an iterative process. When designing feedback reports, refining measures, data, and display may enable report designers to improve the user centeredness of feedback reports.http://deepblue.lib.umich.edu/bitstream/2027.42/173835/1/13012_2019_Article_950.pd