Table 3.

Barriers to LCS Dissemination and Implementation

Eligibility assessment	• Screening guidelines do not account for racial, ethnic, sex, or socioeconomic differences in smoking behaviors or lung cancer risk
	• Guidelines may not be optimized for PLHIV
	• Screening varies by insurance status
	• Inaccurate tobacco pack-years history
	• Discordance between EHR smoking history and actual tobacco pack-years history preventing referral
SDM	• Shared decision aids may not be appropriate for populations with limited health literacy or SMI and may not be available in different languages
	• Individuals may not understand numeracy concepts for informed decision-making
Healthcare-system and provider level	• Multidisciplinary buy-in for implementation
	• Investment by health systems in additional resources (personnel, information technology, etc.)
	• Provider time constraints preventing SDM
	• Level of provider familiarity with LCS eligibility criteria and SDM requirements
	• Implicit bias and differences in trust and perception based on sex, race, ethnicity, and socioeconomic status
Patient level	• Individuals who smoke tend to be less educated and less likely to have a PCP, reducing access to LCS
	• Smoking carries a stigma, with many who smoke having a high level of nihilism
	• Cost and lack of health insurance
	• Travel to LCS facility
	• Medical mistrust
Geographic location	• An inverse relationship exists between individuals at highest risk for lung cancer and availability of accredited LCS programs
	• The southeastern United States has a disproportionately low number of accredited sites compared with the number of individuals who smoke and are at risk for lung cancer

Definition of abbreviations: EHR = electronic health record; LCS = lung cancer screening; PCP = primary care provider; PLHIV = people living with HIV; SDM = shared decision-making; SMI = serious mental illness.