Evaluation of a Scalable Decision Support and Shared Decision Making Tool for Lung Cancer Screening

The purpose of this project is to increase appropriate low-dose computed tomography (LDCT) lung cancer screening through the development and wide dissemination of patient-centered clinical decision support (CDS) tools that (1) are integrated with the electronic health record (EHR) and clinical workflows, (2) prompt for shared decision making (SDM) when patients meet screening criteria, and (3) enable effective SDM using individually-tailored information on the potential benefits and harms of screening. The study will promote standard of care that is endorsed by the Centers for Medicare & Medicaid Services (CMS) and the US Preventive Services Task Force (USPSTF).

The purpose of this project is to increase appropriate low-dose computed tomography (LDCT) lung cancer screening through the development and wide dissemination of patient-centered clinical decision support (CDS) tools that (1) are integrated with the electronic health record (EHR) and clinical workflows, (2) prompt for shared decision making (SDM) when patients meet screening criteria, and (3) enable effective SDM using individually-tailored information on the potential benefits and harms of screening. The study will promote standard of care that is endorsed by the Centers for Medicare & Medicaid Services (CMS) and the US Preventive Services Task Force (USPSTF). This project is supported both operationally and by an Agency for Healthcare Research and Quality (AHRQ) R18 grant. This project will leverage Decision Precision, a validated Web-based tool for LDCT SDM developed at the Veterans Health Administration, as well as an initial version of Decision Precision+, an EHR-integrated version of the tool which can be accessed directly in the EHR and auto-populate relevant patient data in the tool instead of requiring manual data entry. This study will be an 18-month interrupted time series study conducted at the University of Utah Health primary care clinics.

This population will consist of patients eligible for, or potentially eligible for, LDCT lung cancer screening according to USPSTF guidelines, who are seen by a pilot user of the intervention. The inclusion criteria are (i) >= 55 years and <= 80 years old at the time of the visit; (ii) does not already have lung cancer; and (iii) meets USPSTF smoking criteria for LDCT screening (30+ pack-year smoking history and current smoker or quit in the past 15 years) or may meet the criteria if a complete smoking history were taken. USPSTF guidelines may change during the study. In particular, it is anticipated that the guidelines may update during the study whereby the minimum age is reduced to 50 (from 55) and the minimum smoking history is reduced to 20 years (from 30). In the event that the USPSTF guidelines change, the intervention will be updated to match the change to the guidelines. We may also update the study evaluation to match the updated USPSTF guidelines.

The intervention will consist of the following core items: An EHR-integrated shared decision making (SDM) tool for providing information on the risks and benefits of lung cancer screening through low-dose computed tomography (LDCT) testing. This intervention is referred to as Decision Precision+. Suggestions in the EHR to offer SDM for LDCT for patients eligible for lung cancer screening according to USPSTF guidelines. These suggestions include those provided by the EHR's "Health Maintenance" module as well as an EHR-integrated "Disease Manager" system for disease management and health maintenance. Improvements may also be introduced based on user feedback. All major enhancements will be introduced with the support and approval of the appropriate governance group. Following roll-out, clinic leaders may also receive periodic feedback on use of the intervention and LDCT screening rates, as well as advice on how to improve intervention adoption.

Change in proportion of patients eligible for LDCT screening per USPSTF guidelines receiving LDCT screening

Through study completion, an average of 18 months for the intervention period and 12 months for the baseline period

Estimated number of lung cancer deaths prevented given the risk profiles of individuals screened with LDCT

Through study completion, an average of 18 months for the intervention period and 12 months for the baseline period

Through study completion, an average of 18 months for the intervention period and 12 months for the baseline period

The rate of usage of the intervention will be measured. The usage will be measured through system logs and data from the enterprise data warehouse. We will also seek to model patient, clinical user, and context predictors of tool usage.

Usability of the intervention will be solicited during the study to support the implementation and make adjustments to the intervention as needed. Towards the end of the evaluation period, usability will be measured though the System Usability Scale survey.

We will report whether investment in a program to promote appropriate screening for lung cancer can lead to a positive financial return on investment. If so, the number of years before such an investment can break even will be reported.

Through study completion, an average of 18 months for the intervention period and 12 months for the baseline period

Inclusion Criteria: receives care at University of Utah primary care clinics; does not already have lung cancer; meets USPSTF criteria for LDCT screening (currently, age >= 55 years and <= 80 years old at the time of the visit; 30+ pack-year smoking history and current smoker or quit in the past 15 years) or may meet the criteria if a complete smoking history were taken. Exclusion Criteria: None

Tammemagi MC, Katki HA, Hocking WG, Church TR, Caporaso N, Kvale PA, Chaturvedi AK, Silvestri GA, Riley TL, Commins J, Berg CD. Selection criteria for lung-cancer screening. N Engl J Med. 2013 Feb 21;368(8):728-36. doi: 10.1056/NEJMoa1211776. Erratum In: N Engl J Med. 2013 Jul 25;369(4):394.