Table 4.
Evidence table summarizing implementation facilitators and barriers at the provider level
| Citation | Target population | Facilitators | Barriers |
|---|---|---|---|
| Ahsan et al. (26) | PCPs (physicians, NPs, and PAs) working in both internal and family medicine specialties | Familiarity with LDCT LCS (knowledge and beliefs about the intervention) | Lack of efficacy and/or evidence, unnecessary diagnostic procedures, unnecessary exposure to radiation; potential for emotional harm (evidence strength and quality); patients’ knowledge deficits—limited awareness of LCS among patients (patient needs and resources); lack of insurance coverage (external policy and incentives); time limitations (implementation climate); limited awareness of LCS among patients, embarrassment about smoking, lower perceived usefulness (knowledge and belief) |
| Coughlin et al. (29) | PCPs (physicians, PAs, and advanced practice nurse who specialize in internal medicine or family practice) in 3 different types of health-care settings in the United States: 1) a university tertiary care center, 2) a public safety net hospital, and 3) 3 community hospitals | Familiarity with LCS guidelines and ability to identify appropriate patients for screening (knowledge and beliefs about the intervention) | Perceived high false-positive rate leading to unnecessary procedures (evidence strength and quality); lack of insurance coverage (external policy and incentives); time constraints (implementation climate); failure of the EHR to notify providers of eligible patients (readiness for implementation; available resources); provider uncertainty of patient eligibility, patient refusal or declining screening (knowledge and beliefs) |
| Dukes et al. (31) | PCPs and cancer specialists for HNC survivors | None provided | Concerns about the high false-positive rate, potential overdiagnosis or overtreatment, and potentially heightened patient anxiety because of false-positives (evidence strength and quality); complexity of the SDM component, clinical challenge of scheduling and monitoring CTs and follow-ups within a typical yearly appointment (complexity); costs of screening and treatment (cost); patient understanding (patient needs and resources); lack of reimbursement for SDM, LCS reimbursement criteria (external policy and incentives); time constraints (implementation climate); provider uncertainty about its benefit for patient population, lack of patient adherence to screening over time (knowledge and belief); potential HNC treatment-related health issues that could complicate screening (executing) |
| Duong et al. (32) | PCPs from the Stanford Health Care System | Being aware or influenced by USPSTF LCS guidelines (evidence strength and quality); believed current screening guidelines were at least moderately effective (knowledge and belief) | Patient can’t afford or lacks insurance (patient needs and resources); time constraints during a patient encounter (implementation climate); lack of patient awareness of LDCT screening, low provider awareness of appropriate screening guidelines (knowledge and belief) |
| Eberth et al. (33) | PCP (primary specialty as general medicine, family medicine, or internal medicine) members of American Medical Association | Believed that the benefits of LDCT outweigh the risks for patients at high risk for lung cancer (relative advantage); provider able to identify the appropriate screening recommendation (knowledge and belief) | Did not think that there is substantial evidence that LDCT screening reduces lung cancer mortality (evidence strength and quality); complexity of the topic (complexity); coverage denials, authorization was required by health insurance companies, lack of insurance coverage, lack of reimbursement to engage in SDM, SDM requirements—a separate office visit (external policy and incentives); out-of-pocket costs are a problem for patients, transportation or financial challenges for the patient, patients’ health literacy (patient needs and resources); not yet making screening discussions a routine part of practice (culture); time limitations (implementation climate; relative priority); difficulty ordering screening in the EHR, lacking decision aids (readiness for implementation); providers uncertain about how to document patient eligibility in the EHR, not knowing where to refer patients for screening, patient refusal/declining screening, fear that screening may undermine smoking cessation efforts (knowledge and belief); institutional requirements that screening be ordered by a pulmonologist, time to document SDM using decision aids (executing) |
| Ersek et al. (34) | Family physicians from the South Carolina chapter of the American Academy of Family Physicians (South Carolina Academy of Family Physicians) | Scientific evidence is strong enough to warrant screening guidelines (evidence strength and quality); LDCT screening benefits outweigh the potential harms for high-risk patients (relative advantage); knowledge of appropriate screening guidelines, knowledge of the closest CT machine available (knowledge and belief) | Concerns about the number of false-positives leading to unnecessary diagnostic procedures, psychological stress and anxiety, and unnecessary exposure to radiation (evidence strength and quality); concern of cost-effectiveness of LDCT (cost); unsure whether CMS covers LDCT LCS, unsure about whether LDCT is offered at facilities (knowledge and belief) |
| Henderson et al. (36) | PCPs (internal and family medicine physicians—attendings and residents) | Providers felt that they had enough knowledge to explain the pros and cons of LCS to patients, belief that screening is beneficial for patients (knowledge and belief) | Lack of efficacy/evidence, too many false-positives—potential for complications and emotional harm (evidence strength and quality); cost to the health-care system (cost); cost to patients (patient needs and resources) |
| Henderson et al. (37) | Pulmonologists and PCPs (physicians in family medicine, internal medicine, and pulmonary medicine) at an academic setting | Providers felt they had enough knowledge to explain the pros and cons of LCS to patients, belief that screening is beneficial for patients (knowledge and belief); provider specialty—pulmonologists were more likely than PCPs to report LCS as beneficial for patients (other attributes) | Too many false-positives—potential for complications and emotional harm (evidence strength and quality); cost to the health-care system (cost); cost to the patient (patient needs and resources); inconsistent recommendations about LCS (knowledge and belief) |
| Hoffman et al. (38) | PCPs in New Mexico clinics for underserved minority populations | None provided | Cost to patient for follow-up testing and cancer treatment, cost to patient for travel and missing work (patient needs and resources); time limitations—providers facing competing patient demands (implementation climate); lack of infrastructure to support the high-quality screening program required by guidelines, lack of technology in rural areas (readiness for implementation; available resources); providers not as confident in their abilities to decide on an appropriate workup of patients with abnormal or positive findings (knowledge and belief) |
| Iaccarino et al. (39) | Pulmonologists (attending physicians) who were active in outpatient pulmonary medicine in VA medical centers | Believed that the evidence for LDCT screening is strong, clinical trial evidence (evidence strength and quality); reduction in mortality with LDCT screening (relative advantage) | High false-positive rate—detection of incidental findings and radiation exposure (evidence strength and quality); high costs (cost); insufficient personnel (structural characteristics); insufficient infrastructure (readiness for implementation; available resources); lack of patient interest, physicians’ belief that screening is not cost effective (knowledge and belief); lack of buy-in (engaging; staff member engagement) |
| Kanodra et al. (40) | PCPs at the Ralph H. Johnson VA Medical Center and outpatient clinics | Evidence for screening—that there is substantial scientific evidence (evidence strength and quality); EHR reminders and system (readiness for implementation; available resources); awareness of USPSTF guidelines (knowledge and belief); screening coordinator—dissemination and dedicated personnel to review screening findings and offer smoking cessation would be needed to operationalize LCS (engaging; formally appointed internal implementation leaders) | Multiple screening guidelines, hard to keep up with (complexity); cost of co-pay (patient needs and resources); time limitations (implementation climate; relative priority) |
| Khairy et al. (41) | Community providers (physicians, NPs, and PAs) at FQHC “look-alike” centers and PCP physicians at an academic setting (Stanford) | LDCT effective in reducing mortality (evidence strength and quality); knowledgeable of LDCT screening based on the NLST and NCCN criteria (knowledge and belief) | False-positive rate—potential harm (evidence strength and quality); patient can’t afford or lacks insurance (patient needs and resources); shortage of trained providers (structural characteristics); complex comorbidities (implementation climate; relative priority); patient unaware of screening (knowledge and belief) |
| Leng et al. (42) | PCPs serving the NYC Chinese community | Viewed screening as effective (relative advantage); use of EHR to refer patients, ease of making referrals (readiness for implementation); correctly stated they would recommend LDCT for the scenario in which it was clinically indicated (knowledge and belief) | Vague screening criteria, patient being worried about radiation exposure (evidence strength and quality); patient’s lack of insurance or patient insurance doesn’t cover the cost of the LDCT, patient’s lack of time for screening (patient needs and resources); patient’s fear of screening, not believing that they’re at risk, patients think they should have symptoms before screening (knowledge and belief) |
| Lewis et al. (43) | Providers who practiced within general internal medicine or family medicine, pulmonology, hematology/oncology, and gynecology within an academic medical center and its affiliated VA hospital and community practices | Higher knowledge associated with accurate referral (knowledge and belief); ordering/referring for LDCT were highest among general internal medicine/PCPs followed by pulmonologists (other personal attributes) | Providers with low guideline knowledge were less likely to perform LDCT LCS (knowledge and belief) |
| McDonnell et al. (46) | NPs practicing in primary care settings | There is substantial evidence that LDCT screening saves lives (evidence strength and quality); the benefits of LDCT outweigh the risks for patients at risk of lung cancer (relative advantage); the ability to bill for SDM visits was a financial incentive to complete the screening (external policy and incentives); EHR reminders and systems to identify appropriate patients (readiness for implementation; available resources); selected LDCT for the correct vignette that reflected the USPSTF criteria (knowledge and belief) | Acknowledged that the false-positive rate is unacceptable (evidence strength and quality); financial constraints—transportation, uninsured patients (patient needs and resources); greatest barrier is that previous authorization was required by health insurance companies (external policy and incentives); experienced tension with clinic colleagues who opted for a different approach to LCS, complex comorbidities, time limitations (implementation climate; tension for change and relative priority); lack of EHR reminders and system, lack of education/training—individual provider knowledge deficits (readiness for implementation; available resources and access to knowledge and information); patients’ knowledge deficits; patient’s fear and the psychological consequences of waiting for follow-up if screening results revealed abnormal results that did not warrant immediate intervention, outright denial, or unwillingness to change behaviors (knowledge and belief) |
| Mukthinuthalapati et al. (49) | PCPs (residents, mid-level providers, and attending physicians) in safety net health-care system (Cook County Health) | Evidence applied to their population (evidence strength and quality); EHR prompts (readiness for implementation; available resources); belief that screening is cost-effective (knowledge and belief); referral rates varied by provider specialty—highest among general internal medicine/PCPs (other personal attributes); receiving statistics about their LCS practices (reflecting and evaluating) | Potential for complications (evidence strength and quality); complex comorbidities (implementation climate; relative priority); inefficient follow-up process, unclear patient smoking history record (readiness for implementation; available resources); providers felt they lacked knowledge regarding the SDM discussion, forgetting to mention screening to patients (knowledge and belief) |
| Rajupet et al. (50) | Physicians in PCP and specialists (oncologists, pulmonologists, radiologists) | Familiarity with the USPSTF LCS guidelines and ability to identify appropriate patients for screening, felt confident and comfortable (knowledge and belief); having sufficient time to counsel about LDCT screening (implementation climate; relative priority) | Concerns with false-positives (evidence strength and quality); insufficient time to counsel patients about screening (implementation climate; relative priority); belief that screening is not cost-effective, not confident in their abilities to decide on an appropriate workup of patients with positive findings (knowledge and belief) |
| Randhawa et al. (51) | PCPs (physicians) in the network offering care to indigent patient population with limited access to health care | None provided | Time constraints (implementation climate; relative priority); unaware that LDCT was recommended by the USPSTF on par with colonoscopy and mammography (knowledge and belief) |
| Simmons et al. (54) | PCPs (active license as a physician, NP or PA) working in a primary care setting in the state of Florida | Knowledge and current LCS recommendation, felt even resistant patients could be swayed with education and a tailored discussion (knowledge and belief) | False-positives (evidence strength and quality); lack of time (implementation climate; relative priority); uncertain of recommendations (knowledge and belief); cost to patient, patient resistance (patient needs and resources) |
CMS = Centers for Medicare and Medicaid Services; CT = computed tomography; EHR = electronic health record; FQHC= federally qualified health centers; HNC = head and neck cancer; LCS = lung cancer screening; LDCT = low-dose chest computed tomography; NCCN = National Comprehensive Cancer Network; NLST = National Lung Screening Trial; NP = nurse practitioner; NYC = New York City; PA = physician assistant; PCP = primary care provider; SDM = shared decision making; USPSTF = US Preventive Services Task Force; VA = Veterans Affairs.