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Principal Investigator: Christopher G. Slatore
Organization: PORTLAND VA MEDICAL CENTER
Fiscal Year: 2024
Funding agency: Veterans Affairs
Background: VA recommends all eligible Veterans be offered lung cancer screening (LCS) using annual low
dose computed tomography (LDCT). VA is working to increase the number of Veterans screened in VA-settings
but many of them will continue to receive LCS care in non-VA settings. There are several gaps in care processes
in both VA and non-VA settings, including low uptake and adherence to recommended follow-up. Non-VA LCS
radiology facilities, especially in rural areas, often do not have adequate resources to ensure high quality.
Significance: Our proposal has the strong potential to improve care for millions of LCS-eligible Veterans and
non-Veterans. The vast majority of eligible patients have not undergone LCS. Of those that have, many are
engaged in LCS programs with poor records of adherence that will expose them to harms of screening without
the benefits. We will examine data and procedures to help VA and non-VA facilities evaluate LCS processes
and identify modifiable components that can positively affect patient outcomes.
Innovation/Impact: First, this proposal will be the first to evaluate LCS processes among Veterans in non-VA
settings. Second, our study will be the largest to date to evaluate patient-centered outcomes among patients
who receive care at likely hundreds of radiology facilities nationwide. Third, we will use a systems dynamics
stock-and-flow modeling approach and thematic qualitative analysis to identify modifiable factors for improving
outcomes for Veterans engaged in LCS and change components to visualize their effects.
Specific Aims - Aim 1a: Among all Veterans, characterize their involvement in lung cancer screening
processes including eligibility assessments, referral and receipt of LDCTs for LCS, and adherence to
recommended follow-up.
Aim 1b: Among Veterans referred for lung cancer screening in VA and non-VA settings, stratify the adherence
to recommended follow-up based on facility-level LCS program availability.
Aim 2: Among Veterans undergoing lung cancer screening processes, evaluate the association of VA and non-
VA communication components with patient-centered outcomes.
Aim 3: Among Veterans, VA clinicians, staff, and leaders, and non-VA radiology facility staff, use qualitative
methods to elicit their perspective on determinants of providing guideline-concordant care to Veterans referred
to VA and non-VA settings for lung cancer screening.
Methodology - Aim 1: Conduct a national audit of Veterans eligible for LCS to evaluate care processes and
adherence to follow-up based on the Lung CT Screening Reporting & Data System. We will link these data
with facility-level information of LCS programs’ characteristics obtained through the National Center for Lung
Cancer Screening, to develop models of the association of VA and non-VA LCS program factors with
adherence to recommended follow-up.
Aim 2: Conduct a nationwide, cross-sectional survey of Veterans referred for LCS in VA and non-VA settings.
We will use validated instruments to measure Veterans’ attitudes about care coordination, decision-making
about choosing LCS community care, communication with VA and non-VA staff, and patient-centered
outcomes such as adherence, decisional regret, satisfaction, and smoking cessation resource utilization. We
will conduct in-depth EHR audits of survey respondents to determine adherence to recommended follow-up.
Aim 3: Guided by a theoretical model of care coordination, we will conduct qualitative interviews of Veterans
and VA and non-VA staff engaged in LCS to collect their thoughts on care coordination and communication
practices. We will also use a stock-and-flow modeling approach and thematic qualitative analysis.
Next Steps/Implementation: We have very engaged partners who will use our results to guide care processes
and plan multiple manuscripts and presentations based on this proposal.
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