Abstract A103: Use of a combined systems and design framework to assess and improve lung cancer screening for underserved rural population
Authors: Hasson Rian M. , Schifferdecker Karen E. , Golding Shaun A. , Bardach Shani , Kinney Linda M. , Boardman Maureen B. , Kyung Ellie , Halloran Sean R. , Youkilis Samuel L. , Perry Amanda N. , Ladage Vrushabh P. , Bird Tom 
Published: January 2023

Abstract
Lung cancer screening (LCS) is severely under-utilized by eligible individuals living in rural areas. The purpose of this study is to increase LCS in a rural population by applying a combined systems and design approach to identify needed health system-level changes and to proactively identify potential facilitators and roadblocks for the changes across multiple levels in an academic medical center. Data to identify system-level processes and gaps included LCS referral and screening data, 26 stakeholder interviews with providers, clinical staff and potential eligible patients, review of health record fields for smoking history, and LCS process mapping, including potential pathways of referral and notification of eligibility. Design thinking was applied by assessing potential facilitators and roadblocks across different levels for changes, including higher-level institution commitment, financial implications of increased LCS (i.e., return on investment), gaps in process-level resources (e.g., accredited scanners, time for shared decision making), and overall stigma related to smoking. Results indicated overall support for LCS by all stakeholders but a lack of knowledge about LCS among potential patients and challenges to easily identify eligible patients and finding time for shared-decision making and smoking cessation required for LCS referrals among providers. Further investigation showed lack of full EHR documentation of smoking history due partially to insufficient fields in the EHR to document full smoking history or to calculate pack years which led to largely inaccurate automated LCS eligibility notifications. Targeted interventions based on the system findings include adding smoking history fields and calculators in the EHR to adequately document smoking history and identify eligible patients, creating an education and question-based pamphlet for patients visiting primary care to prompt accurate history documentation and LCS conversation, provider letters to highlight an existing Lung Health Center resource for SDM and smoking cessation, avoiding stigmatizing language (e.g., “smoker”), and highlighting health versus cancer (Lung Health Check versus Lung Cancer Screening) in patient-facing materials. Application of design thinking led to identifying sustainable interventions within existing processes and arranging leadership meetings to establish LCS ROI and personnel/equipment justifications to support and sustain increased LCS referrals. Models of healthcare improvement, such as those promoted by the Institute for Healthcare Improvement, focus largely on system-level analyses without adequate attention to design thinking which may lead to interventions that are limited in scope or subject to obstacles that limit success. This study demonstrates that using wider and multiple lens for improving LCS in a rural population allows for human-centered and system-centered approaches that may better address gaps in care for individuals at high risk for inadequate care and provide them services that they deserve.
Citation Format: Rian M. Hasson, Karen E. Schifferdecker, Shaun A. Golding, Shani Bardach, Linda M. Kinney, Maureen B. Boardman, Ellie Kyung, Sean R. Halloran, Samuel L. Youkilis, Amanda N. Perry, Vrushabh P. Ladage, Tom Bird. Use of a combined systems and design framework to assess and improve lung cancer screening for underserved rural population [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A103.