Shared Decision Making in Rural Primary Care Lung Cancer Screening and Smoking Cessation (SDM-LCS-SC)

The intervention is aimed to improve adherence to the lung cancer screening (LCS) guidelines and Centers for Medicare and Medicaid Services (CMS) coverage criteria to conduct shared decision-making (SDM) and provide smoking cessation services in rural primary care practices.

The pilot intervention will engage no more than 300 patients using a pragmatic, pre-post design guided by an enhanced RE-AIM/PRISM framework. The primary goal of this intervention is to improve LCS practice by offering a formal SDM process and smoking cessation support aligned with the CMS coverage criteria. The investigators will conduct a type II effectiveness implementation hybrid trial using a stepped wedge design to evaluate the effectiveness (co-primary outcomes of LCS and decision quality) and implementation at four rural clinics. Space precludes discussion of pragmatic design features, but this study was designed to be pragmatic using the PRECIS-2 criteria and it scores highly on almost all PRECIS-2 dimensions. Each clinic will recruit the minimum of 9 patients eligible to LCS (based on CMS guidelines) every 2 months for the total of 8 months. The first period of 2 months is for baseline data, the second period of 2 months is for step 1 of the stepped wedge design, the third period of 2 months is for step 2 and finally the last 4th period of 2 months is for step 3 of the stepped wedge design. Each participating patient will receive 2 surveys (one immediately after the doctor's visit and a second one a month later). The intervention will be in the form of patient decision aid (information flyer) the participant receives during a healthcare provider visit.

A type II effectiveness implementation hybrid trial will be conducted using a pre-post design to evaluate the effectiveness (co-primary outcomes of LCS and decision quality) and implementation at four rural clinics.

The control group will consist of each participant and clinic before the intervention (baseline, first 2 months).

The intervention group will consist of each participant and clinic once they move to the intervention phase (stepped-wedge design: practices will be randomized into step 1, 2 or 3; for step 1: the intervention will start at 2 months, for step 2: the intervention will start at 4 months, for step 3: the intervention will start at 6 months).

Each subject will receive an informational flyer describing lung cancer screening options and smoking cessation from a trained person on the medical staff at each clinic. Staff will lead a shared decision-making discussion with the patient.

Count of participants who's health visit adhered to the LCS guidelines and CMS coverage criteria in rural primary care practices: baseline survey

The adherence to the LCS guidelines and CMS coverage criteria to conduct SDM and provide smoking cessation services in rural primary care practices (is a latent variable) and will be measured as a composite measure using variables in a baseline survey administered immediately after healthcare provider's visit (baseline). A survey tool will be developed and used to count "Yes" response to the following survey questions: Were you given a decision aid during your last clinic visit/call? Was the clinic provider or staff able to go over the decision aid together with you during your last clinic visit/call? Were you recommended for a low-dose CAT scan by your provider during your last clinic visit/call?

Count of participants who's health visit adhered to the LCS guidelines and CMS coverage criteria in rural primary care practices: follow-up survey

The adherence to the LCS guidelines and CMS coverage criteria to conduct SDM and provide smoking cessation services in rural primary care practices (is a latent variable) and will be measured as a composite measure using variables in a baseline survey administered immediately after healthcare provider's visit (follow-up). A survey tool will be developed and used to count "Yes" response to the following survey questions: Were you given a decision aid during your last clinic visit/call? Was the clinic provider or staff able to go over the decision aid together with you during your last clinic visit/call? Were you recommended for a low-dose CAT scan by your provider during your last clinic visit/call?

Patient knowledge about lung cancer will be measured by 5 survey questions previously used by Lau et al in their peer reviewed manuscript published in American Journal of Preventive Medicine titled Evaluation of a Personalized, Web-Based Decision Aid for Lung Cancer Screening (2015 Dec;49(6):e125-9. doi: 10.1016/j.amepre.2015.07.027). The level of knowledge will be assessed based on correct answers to the following survey questions: Factors that increase chances of developing lung cancer include; Possible benefits of lung cancer screening are; Possible harms of lung cancer screening include; Please indicate whether each of the following individuals would be eligible for screening based on their age. They all meet the smoking status and pack-year criteria; What percentage of lumps found on your lungs by the CT screening is NOT going to be cancer? More correct answers indicate higher level of knowledge.

Patient knowledge about lung cancer will be measured by 5 survey questions previously used by Lau et al in their peer reviewed manuscript published in American Journal of Preventive Medicine titled Evaluation of a Personalized, Web-Based Decision Aid for Lung Cancer Screening (2015 Dec;49(6):e125-9. doi: 10.1016/j.amepre.2015.07.027). The level of knowledge will be assessed based on correct answers to the following survey questions: Factors that increase chances of developing lung cancer include; Possible benefits of lung cancer screening are; Possible harms of lung cancer screening include; Please indicate whether each of the following individuals would be eligible for screening based on their age. They all meet the smoking status and pack-year criteria; What percentage of lumps found on your lungs by the CT screening is NOT going to be cancer? More correct answers indicate higher level of knowledge.

Inclusion Criteria: Asymptomatic to lung cancer symptoms Tobacco smoking history of 20+ pack-years Current smoker or quit within last 15 years Exclusion Criteria: - A patient that does not meet inclusion criteria