Implementation of Lung Cancer Screening in Primary Care and Pulmonary Clinics: Pragmatic Clinical Trial of Electronic Health Record-Integrated Everyday Shared Decision Making Tool and Clinician-Facing Prompts.

BACKGROUND: While low-dose computed tomography (LDCT) lung cancer screening (LCS) can reduce lung cancer mortality, it remains underutilized. Shared decision making (SDM) is recommended to assess the balance of benefits and harms for each patient.

RESEARCH QUESTION: Do clinician-facing electronic health record (EHR) prompts and an EHR-integrated "Everyday" SDM tool designed to support routine incorporation of SDM into primary care improve LDCT ordering and completion?

STUDY DESIGN AND METHODS: A pre-post intervention analysis was conducted in 30 primary care and 4 pulmonary clinics for visits with patients who met US Preventive Services Task Force criteria for LCS. Propensity scores were used to adjust for covariates. Subgroup analyses were conducted based on the expected benefit from screening (high-benefit vs intermediate-benefit), pulmonologist involvement (i.e., whether the patient was seen in a pulmonary clinic in addition to a primary care clinic), sex, and race/ethnicity.

RESULTS: In the 12-month pre-intervention phase among 1090 eligible patients, 77 (7.1%) had LDCT orders and 48 (4.4%) completed screenings. In the 9-month intervention phase among 1026 eligible patients, 280 (27.3%) had orders and 182 (17.7%) completed screenings. Adjusted odds ratios were 4.9 (95% CI: 3.4, 6.9, p<0.001) and 4.7 (95% CI: 3.1, 7.1, p<0.001) for LDCT ordering and completion, respectively. Subgroup analyses showed increases in ordering and completion for all patient subgroups. In the intervention phase, the SDM tool was used by 23 (22.5%) of 102 ordering providers and for 69 (25.2%) out of 274 patients for whom LDCT was ordered and who needed SDM at the time of ordering.

INTERPRETATION: Clinician-facing EHR prompts and an EHR-integrated Everyday SDM tool are promising approaches to improving LCS in the primary care setting. There is still room for improvement, however. As such, further research is warranted.

CLINICAL TRIAL REGISTRATION NUMBER: NCT04498052.