Table 4.

Illustrative quotations demonstrating themes by RE-AIM domain

Participant role – Theme	Quotations
Reach: Illustrating the hassles involved with LCS across groups or anticipated resistance
Clinicians/ Provider – LCS	“Most people are pretty open to it…We always have a few that are like, “I don’t wanna know.” But most do follow through for the appointment, yes.” [MD1 60004] “I think the two biggest impediments I see to people getting that done are, well, probably three things: one is cost; one is difficulty of getting there, and spending a whole day coming and goin’; and the third thing is, you know, a lot of ‘em say, “Well, if I get lung cancer, it’s my time. I’ll go, you know. I’ll take my chances.” [Laughs – 26.17]. “If God wants me to go, I’ll go.”” [MD1 60003]
Clinical Staff – LCS	“You know, with the Obama care, the colorectal, the mammogram, the pap, the prostate, annuals, all those are covered on your insurance by law. All insurances have to cover those screens, but the lung cancer’s still not on there. The last time I tried to get an authorization on any of the insurances except for Medicare, 65 and older… it’s just a wall” [PN1 60001]
Clinical Staff – SC	“A lot of information given to the patients, really, and because we’re so small, the provider, she’s got everything laid out and ready to go. So, [laughing] it’s a matter of just going and grabbin’ it, and handing it to the patient, or you know, we do a lot of—our records are kept through electronic health records. And so, a lot of communicating that way sometimes, also is done as far as providing information.” [MA1 60004]
Administrators – LCS	“I’m not positive because, again, I’m not in that part of the EMR, but I think they send them to Community, or depending on their insurance, over to St. Mary’s. But I’m not sure ‘cause I have never ordered one.” [AD1 60002]
Administrators – SC	“I guess once they say, “Yes. I smoke. No. I don’t wanna quit. I don’t even wanna hear anything about it.” Then, again, it’s just personal, like, what can you do as to the physician. I mean, again, he can tell them anything they want and screen ‘em and give ‘em options, but it’s the person that needs to do the change.” [PM1 51105]
Patient – LCS  -  Not willing to address	“It’s like sticking your head in the sand.” [P2 70002]
Patient – LCS  -  For screening	“Yeah. It’d be nice to know if it was there. I mean especially I smoked so long. Again, I mean it would be nice to know. If I have lung cancer, I don’t know what I would do about it at this age. I mean I’m not sure which way I’d go on it, but yeah, it’d be nice to know.” [P2 60001]
Patient – LCS  -  Against screening	“[Y]es, I smoke. I know that’s not good, but I’ve never had… any problems that makes me think, oh, I guess I better go get this checked out… Well, I think that –it is something I think that in my generation…you just didn’t go to the doctor just because of this or that. And I am still kind of one of those that, oh, let’s just give it a while and see if it gets better on its own.” [P3 51401] “You know, lung screens, all those things are not paid for…And when you have $6,000 deductibles and then… we only have [a] hospital, so that means when I’ve had to have some x-rays…I had to leave town or otherwise they were gonna be $500. Where if you left town, they’re $125. So, there is a cost associated with it, and people say, “Well, how much do you pay for some cigarettes.” I mean I hear [inaudible] verse the back and forth, but you’re not talking hundreds of dollars all at one time, you know.” [P3 51401] “Well, probably ‘cause in my mind it’s when I see it, then it’s probably too late, or unfixable, or maybe it’s ‘cause I don’t wanna take the first step to stop. I’m not really sure what the fear is… Kind of don’t fix it if it ain’t broke rather than I’m thinkin’ it might be patched up right now. So, maybe, like, patched together.” [P4 60002]
Patient – SC  -  For SC	“Because my surgeon told me—it’s the surgeon that saved my life told me, “If you keep smoking cigarettes, you’re going to die.”… maybe I really don’t need that frickin’ cigarette… I have no desire to pick up a cigarette. Done. No cravings, no desires, none.” [P2 60002]
Patient – SC  -  Against SC	“I think my doctor knows that I smoke anyway. Not that I told, so I don’t think it’s any of her business. Then I wouldn’t have a life if I stopped smokin’ and drinking—a beer every now and then. If I stop smoking and drinkin’ beers, what am I gonna do? Other than watch TV already. I do that.” [P3 51105]
Effectiveness: Illustrating patient versus practice member discrepancy on the importance of LCS
Clinicians/ Provider – LCS	“I definitely think it’s important, but I value it and look at it all as the same of all cancer screening preventative measure. And usually that’s [what I] tell every patient, we only have so many things that help to screen and prevent for cancer and might as well do ‘em… A lot of cancers that we don’t—we can’t screen for, so you know, this is one. So, take what we have resources for.” [PA1 70001]
Clinicians/ Provider – SC	“I think it would be better use of time to get ‘em to stop smoking because that pertains not only to cancer…So, you’re hitting more boxes if you get ‘em to stop smoking, I think. But that’s assuming that that intervention of talking to them about smoking cessation [is heard]. You’re odds of getting ‘em to go do screening are better than your odds of getting ‘em to quit smoking. You really ought a do both though.” [MD1 60003] “Very, very important. So, the earlier we can catch these risk factors and catch people with conditions, the better. Definitely.” [CC1 60001] “It’s usually fairly high up my list. If I have something that might be currently threatening their life…we will probably not talk about smoking cessation…But if there’s any room for any conversation about how to improve your health rather than just dealing with the most urgent acute issue, then smoking cessation is high on that list. [MD1 51105]
Clinical Staff – LCS	“The first one…he was around my age, and he was not feeling well….And we had done x-rays of the chest….And so, when we finally had done multiple imagining…something come up on a CT… And he was upset because we didn’t find that sooner…And I was in on most of those appointments, and there was never anything like, “I can’t get rid of this cough,” [I]t wasn’t something you’d just say, we outta check your lungs. He was a smoker, so this 30-pack, you know, all the guidelines for the lung cancer screening probably would have got him in quicker for a lung screen. But anyway, he ended up with small-cell lung cancer…but he did pass away from that…and it was very sad. [PN1 60001]
Clinical Staff—SC	“I know they do the discuss risks and benefits. And other than that—I just feel like they’re just referred out to quit line and stuff like that, unless they’re going to start taking medication, then it’s kind of like they’re prescribed medication, and then it’s like, okay. We’ll follow up, and then they come back and follow up, and then just kind of go that route, but other than that, I don’t feel like there’s much done about it.” [MA1 51105]
Administrator – LCS	“I think it’s probably pretty important. I’m not sure that we remember to do it all the time. But I do think at least, at the very least, asking the questions about risk factors, that piece of the screening is super important.” [AD1 70002]
Administrator—SC	“I think it’s like everything else. Patient needs to be aware of the risk, and sometimes it’s anything just like any other disease. I think it’s also cultural, you know, well, before people—it was normal to smoke. So, it’s their culture to think that it’s—it’s just normal. But, yeah, it’s important just like any other disease, too, to say, you know, it’s bad, and this is what’s gonna happen, and then give ‘em risk and consequences, yes.” [PM1 51105]
Patient – LCS	“But that was a good experience, you know, just talking to my provider. And when they mentioned all this stuff about lung cancer and everything, and that’s kind of scary. But they were real encouraging, and very supportive, so that was a good thing. When you feel comfortable in the clinic talking to your PA, you know, it makes a lot a difference. And I feel better now, so yeah, that is a good experience. I feel better.” [P4 70001] “I understand I don’t need to smoke. I need to stop. I got it. But sometimes that’s easier said than done.” [P1 60004]
Patient -SC	“I just quit smoking. And they’d say, “Good for you!” You know, I mean that was an encouragement…I was excited about that because they said, “Good for you.” But they really don’t make you feel ashamed.” [P1 51401]
Adoption: Illustrating practice member barriers to doing LCS
Clinician/ Provider – LCS	[W]e always talk about low-dose CT—LDCT. And I’m not sure how that’s different from the CT that they do when I order a CT of the chest…[the] reports always come back, “We used the lowest possible dose,”… Do they, or is low-dose CT for lung cancer screening something special that only limited number of places have? [ MD1 60003] “I just worry about is the whole radiation side of things. I’m not very good about recommending it every year. I will recommend it, but then I don’t always, like, feel super excited about in a year’s time saying, you need to go get this again. If it’s been several years, then I feel more comfortable.” [MD1 60001]
Clinician/Provider – LCS and SDM	“It’s fairly simple. I mean, so you’ve been smoking for a long time. It’s now recommended that you have screening. There’s a low-dose CAT scan that they do to look for any signs of lung cancer. It’s usually recommended yearly. Is it okay if I go ahead and send a referral for you to do that?”… I don’t have a tool, no.” [MD1 60004]
Clinician/Provider – SC	“We assess their smoking. That happens annually… [S]o it’s actually one of the quality or we call it our QI tab. So, if it’s been over a year, we get an alert that says we need to assess it. So, it’s definitely done once a year…. [I]t is on our annual questionnaire, so we have patients fill out a review of systems, basically, and it’s also one of the questions on that. So, that’s once a year, and if it’s not written down, then the clinician asks. [MD1 60002] “Well, we ask them about their smoking history at every visit, and you’ll have to check with the frontline staff as to what their protocol is as far as what they offer the patient at that point in the visit.” [MD1 60003]
Clinical Staff – LCS	“That’s something the provider does, and I’m not sure what kind of assessment they do to determine if that patient is eligible. So, that’ll have to be a conversation that, you know, with my provider.” [LPN1 70002]
Administrator –LCS	“I’m not for sure. That would be a question for one of our providers.” [AD1 70001] “So, we don’t necessarily have like a process of if they have this, then they can get this. It’s usually done by the provider, so the provider usually makes that call and puts in the order and stuff like that. It’s not usually done by the nursing staff. The provider’s the one to say, like, “Oh, yeah. They need this done.” But we don’t necessarily have like certain guidelines that the nurses go through to say, yeah, this one’s gonna need a CT low dose.” [AD1 70003]
Administrator—SC	“We usually ask people if they’re interested in quitting smoking, and we usually tell ‘em, you know, the only think smoking’s good for is cancer or heart disease, and high blood pressure. And then, if they’re not really interested at that point in time in quitting smoking, we kind of just sort of let the conversation go. If they say, “Yeah. I’m interested in it.” Then, you know, we can start talking about the options that are available.” [AD1 70002]
Patient – LCS	“No. She hasn’t ever talked to me about it. The only thing she talked to me about was quitting—to quit smoking. That was it.” [P1 70003] “It was pretty much, like you know, “Well, they have lung cancer screening now, and you could be a good candidate.” And I said no.” [P1 60002] “Umm just that she thought I should do it because I smoked for so long, my mother died of cancer, you know, lung cancer I should say, and at that time I was still smoking.” [P2 51105] “I get it once a year, I guess. But whatever it is, yeah. I know how she’s—and she’s always on top of my smoking, when I’m smoking, and my drinking. She’s on top of that too… She just wants me to be aware.” [P2 60001]

LCS Lung cancer screening, SC Smoking cession, SDM Shared decision making