Expanding Lung Cancer Screening to Achieve Excellence (EXHALE) - Annual low-dose computed tomography (LDCT) has the potential to reduce lung cancer mortality by ~20% and has been a US Preventive Services Task Force (USPSTF) recommendation for 10+ years. However, lung cancer screening (LCS) currently falls well below thresholds to achieve population-level benefits and clinics are unprepared for the introduction of LCS national quality metrics. Widespread adoption of LCS has multilevel barriers, including a complex, multistep process spanning patient identification to follow-up testing for abnormal results and repeat annual screening. Federally Qualified Health Centers (FQHCs), which serve a high proportion of LCS-eligible adults and have relatively low LCS rates, struggle with these barriers. Our proposed project, Expanding Lung Cancer Screening to Achieve Excellence (EXHALE), will develop evidence-based, pragmatic and scalable implementation strategies to increase LCS in representative practice settings. We will form a partnership of 7 FQHC systems—including the largest in the US—with 3 NCI-designated comprehensive cancer centers and a major healthcare system research center. We will adapt, scale and evaluate a proven multicomponent implementation strategy to increase guideline-concordant care using learning collaboratives and practice facilitation (PF) based on the Project Extension of Community Health Outcomes (Project ECHO) model. EXHALE is guided through the phases of implementation by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. In the implementation phase, we will conduct a 2-arm pragmatic randomized clinical trial (RCT). Our study setting includes 7 FQHC systems with a total of 108 clinics and ~22,000 LCS eligible adults. Our primary outcomes will be measured at 12 months into sustainment. Further, we will re-randomize clinics in a micro-trial to test audit and feedback reporting of LCS to compare differences in sustainment at 18 months. We propose three aims for both UG3 (planning) and UH3 (scale): UG3-Aim 1: Define data processes and clinical workflows to identify eligible patients and track LCS outcomes; UG3-Aim 2: Use validated approaches to adapt an existing resource library, ECHO learning collaborative curriculum, and embedded PF strategies; and UG3-Aim 3. Assess clinical care processes, readiness, and capacity in recruitment of >60 FQHC clinics in 7 states. UH3-Aim 1. Assess the scale-up of LCS; UH3-Aim2. Compare the effectiveness of LCS implementation strategies across LCS; and UH3-Aim3. Evaluate contextual factors affecting sustainability of LCS interventions, and track adaptation to interventions and implementation strategies. We will implement a practical, high-frequency/low-intensity strategy for scaling LCS with minimal provider and system effort. By collaborating with FQHCs, we ensure our strategies are flexible and sustainable to reach people at high-risk for lung cancer. In all aims, EXHALE addresses rigor through study design, methods, partner engagement, and dissemination of study findings.
