The role of providers in low-dose computed tomography screening. Most NPs were adamant that recommendations for screening lay squarely within the primary care provider’s scope of practice and that they (the NPs) should take advantage of every engagement opportunity to suggest LDCT screening if the patient met the eligibility criteria for it: “I think the majority of the time, the primary care provider should be the one discussing these things with the patient, and then send them to the specialist.
Respectful working relationships with local pulmonologists or other specialists facilitated follow-up care if screening indicated the need for a referral:
We have a handful of pulmonologists that we use frequently, and we have a very good relationship, where I could call them on the phone and say, “Hey, I’m going to be sending this patient to you. This is their name. This is what I’m concerned about.” And they’ll be like, “Okay, great, thanks for the heads-up. We’ll look out for them.”
However, NPs often needed to creatively negotiate system constraints associated with ordering the screening, such as obtaining insurance approval:
Well, I don’t think I would have a problem doing it myself [ordering LDCT screening], but it definitely has a higher rate of approval if a specialist is ordering it, and then referring it to me to actually do the manual work.
The influence of others on decision making about screening. The NPs interviewed for this study generally evaluated their patients and made evidence-based recommendations. However, there were circumstances in which some NPs felt compelled to practice in ways contrary to established lung cancer screening guidelines. For example, although these NPs did not experience conflict with specialists such as pulmonologists, some experienced tension with clinic colleagues who opted for a different approach to lung cancer screening. One related how the power differential between her and her physician employer (who had a financial interest in CXR screening) influenced the screening process implemented at her practice site:
Well, it [LDCT] is supposed to be more efficient at screening for lung cancer than just routinely doing xrays, which [pause] the other physician in my office did a lot more chest x-rays on patients with a high smoking history who were over 50… [He] recommended that you offer them an x-ray, because it was incredibly cost-efficient and convenient at our site.
Consideration of patient desires and fears also affected NP decision making:
I think everybody has probably sent somebody for screening who really didn’t meet criteria, but they were just so anxious about it, and spent so much of their time thinking about this . . . that they’re just better off with, “Okay, let’s go get it done, if that’s what’ll, you know, help you sleep at night.”
Theme 2: Guideline adherence—Identifying and responding to patient challenges. The NPs interviewed for this study consistently conveyed that the ability to provide excellent care was impossible without understanding the patient’s circumstances. However, this understanding often affected their ability or willingness to recommend LDCT screening.
I need to advocate for the patient. Is this the best time for this patient to undergo a cancer screening? What are this patient’s health care priorities?
Complex comorbidities. Screening for a potential problem seemed trivial when faced with the need to address existing, substantial concerns. Each NP related an experience with the multitude of patient issues that required attention during each appointment. One NP noted:
So you have to cover diabetes, hypertension, anemia, anything else, in that visit. Oh, and by the way, they probably have bronchitis or some other illness . . . . They have an infestation of bedbugs, or scabies, or something else that you have to talk to them about.
The NPs also expressed the need to consider the patient’s priorities:
It just seems like—at least, my population that I serve is very sick, underserved, underinsured, and usually the least of their concerns is that something may potentially be happening. They’re more worried about what is happening. Or what they perceive to be a problem, more so than what health-care providers perceive as a problem.
These NPs related that the reliance on acute, episodic care by the vast majority of their patients, coupled with patient resistance to preventive care, often resulted in unrealistic patient expectations:
I mean, we are a quick Band-Aid America these days. Everybody wants to continue to eat their junk food and smoke their cigarettes, and then they want to come to the hospital for a quick fix. They want me to fix it immediately. Honestly, I think that is the problem.
Nurse practitioner-related delays in appropriate care. Most of our patients are seeing us for the first time. They haven’t seen a provider in 10 years or longer, and they’ve never had any screenings done. Being referred to one more provider is going to take time . . . . So, when they already haven’t had healthcare for 10 years, making them wait months to see a specialist is just delaying their care longer.
Patient knowledge and attitudes. In addition to considering patients’ complex physical issues, NPs also had to take into account patients’ knowledge deficits related to a lack of public awareness. One NP said:
The American Heart Association has done a great job. Everybody wants to know their cholesterol level. You hear a lot about that and other screenings like Pap smears. But I don’t think that I’ve ever had one person ask about lung cancer screening.
Nurse practitioners also reported encountering patient fear and the psychological consequences of waiting for follow-up if LDCT screening revealed a suspicious nodule that did not warrant immediate intervention. A common occurrence encountered by these NPs was a sense of fatalism on the part of patients that was difficult to overcome:
The biggest barrier is that they’ve made their mind up. They’re set in their ways. You know, they’re going to die of something, so—why not lung cancer? I don’t know. They have that kind of mentality. So the patient actually being open to it—that’s the biggest barrier we hit.
Another common occurrence was outright denial or unwillingness to change behaviors:
A couple of them have said that they don’t want something [i.e., lung cancer screening] because, “Well I don’t plan on quitting smoking, so I don’t want to have any testing done.” And then I’ve had a couple [of patients] who say, “Well, if I found something, I wouldn’t want to know.”
Financial constraints. Practical issues such as economic pressures on patients are well documented and were a concern as well. A common experience among NPs when developing patient care plans was a perceived responsibility to consider how following LDCT recommendation guidelines may financially affect their patients:
I talk to them about lung cancer screening, and the hospital that we’re associated with charges, I think, like 99 bucks for a LDCT. But most of them can’t afford a $4 prescription, let alone $100 for a CT scan.
Even the costs associated with transportation were problematic for some patients:
For some of my patients who are on fixed or very little income, it’s hard for them to actually get to one of the hospitals that can do the screening. Gas money seems to be a barrier for them.
In many NP practice locations, insurance covered the initial screening CT. However, if a suspicious nodule was identified, any follow-up imaging was considered diagnostic rather than preventive and was not covered by insurance, thus making it cost prohibitive: “A lot of these low-cost insurances have very high deductibles, like $6,000 deductibles. And that’s really a lot of pressure for some families.”
The financial burden of follow-up affects patient decision making. One NP reported “Once they’ve been screened, they don’t want to go and do it again every year. They say, ‘Okay, I’m fine, there’s nothing wrong with me. Maybe in a few years I’ll check again.’” Financial concerns also affected provider decision making:
A lot of our patients have high deductibles and, you know, out-of-pocket expenses for patients are high. So, unless they’re sick, I oftentimes don’t talk people into doing things that cost a lot of money.
Responding to barriers. Nurse practitioners also had to consider the implications of screening barriers when assessing patients’ need for screening and facilitate negotiation of these challenges. One NP took a professional self-preservation approach when faced with patients unwilling to follow provider recommendations:
I do hear about some providers who dismiss a patient from their practice around issues like that. You know,“If you’re not going to follow the guidelines, then I don’t want a bad outcome on me.” That sort of mode of thinking. But we would not do that in our practice.
Nevertheless, in general, NPs reported using their knowledge of the contextual and individual patient factors to craft targeted interventions designed to facilitate better patient outcomes. For example, one NP anticipated potential patient barriers in the face of a positive screening result and incorporated solutions into patient care plans:
[I] bring them back into the office. I usually call them myself. I don’t let the secretaries or the medical assistants call. I just say,“We need to talk,” and,“Can you come in today?” I will already have an immediate appointment set up with a respiratory specialist. And then when they come in, I have the next appointment scheduled. “Well, you’re going to see Dr. Smith at four o’clock tomorrow.” I don’t want it to wait and that’s the way I handle it.
Other NPs included pragmatic solutions targeted to their particular location and patient population: “We implemented a service at our office, because of how poor our population is, where we actually pay for a taxi service so that they can travel to their appointments.”
Theme 3: Optimizing evidence-based practice—Provider facilitators and barriers. The NPs in this study identified specific tools and structural conditions that facilitated or hindered their ability to offer appropriate LDCT screening to their patients.
Financial incentives. For some NPs, the ability to bill for SDM visits was a financial incentive to complete the screenings:
Actually, our coder who comes around at least once monthly had mentioned that [ability to bill for SDM visits] to us before. I think we’re still trying to work on how to be more proficient in that, so that it doesn’t become too time-consuming compared to the amount of revenue [laughs] that you can bill for.
Optimal system management. When clinic systems (such as electronic medical record reminders) and personnel knowledge were congruent regarding LDCT screening, the NPs felt supported in their ability to provide appropriate screening recommendations to their patients, and patients were much less likely to be overlooked:
We use a check-off sheet with our patients, when they’re coming in for an annual exam. One of the questions prompts us to remember to ask them about screening… I think it’s like auto-populated in our electronic medical record. Because the guidelines are always changing, it’s hard to keep it straight… I think that the tool being built into our electronic medical record really helps…We have a very good administrative assistant in our office who handles all the referrals. She’s like the referral manager. And she does a really good job at getting insurance approval and this and that.
Provider inhibitors. When systems were not coordinated to facilitate individual practice, NPs indicated that they forgot to offer the screening or other concerns took precedence. Other inhibitors to optimal, evidence-based practice included individual provider knowledge deficits:
I’m really personally nervous about the radiation exposure. And I didn’t know that we can just jump to CT, or that we can start out screening with CT first. I thought it had to be chest x-ray first. Since that’s what most of my colleagues are doing, that’s what I tend to do too. So I haven’t really just jumped to CT.
Another inhibitor is ingrained group practice patterns: “And I think we are so ingrained in doing chest x-rays first . . . [laughs] because that’s been the longest practice. Do a chest x-ray. You know? So, this is relatively actually new, doing the LDCT scans.” Finally, in rural settings, provider turnover inhibited NPs’ ability to provide consistent care within their practice setting:
We have a lot of turnover with physicians and even nursing staff, currently. So until we can keep people long enough to start setting up some of that stuff, I don’t know if it’s ever going to happen. In rural communities, we get a lot of physicians who come here for short periods of time. You know, they sign a contract to work here to pay off their school loans for a couple, 3 years, and then they go home. It’s a rural area. People don’t dig it here.
Mapping quantitative and qualitative data
Mixing methods (i.e., collecting quantitative and qualitative data) facilitated a deeper interpretation of the survey responses. Both quantitative data generated by the survey and qualitative data generated from the telephone interviews were mapped against the conceptual framework of sequential change as proposed by Cabana et al. (1999). The framework (Figure 1) characterizes barriers as related to knowledge, attitudes, and behaviors. Our data show a high level of congruence between the conceptual framework and the quantitative and qualitative data.
Discussion
Clinical practice guidelines are systematically developed statements designed to guide health care providers and consumers in making decisions about the best care for specific clinical situations (Cabana et al., 1999). Successful guideline implementation accelerates the translation of research advances into clinical practice. However, the uptake of newly approved guidelines for cancer screening is a slow process that can be challenging and complex for practitioners in clinical or community-based settings (Kinsinger et al., 2017). Physician adherence to cancer screening guidelines is commonly studied. However, NP adherence is less studied and yet is critical to the translation of screening recommendations into improved outcomes (Haas et al., 2016). Nurse practitioners comprise the largest group of nonphysician primary care providers in the United States, and in rural areas they are becoming more central to the provision of primary care, especially for underserved, at-risk populations (Agency for Healthcare Research and Quality, 2012; Spetz, Skillman, & Andrilla, 2017).
In this national study, the response rate was lower than expected, despite using two response modalities. We implicate four factors with this response rate. First, the American Association for Public Opinion Research (AAPOR) acknowledges that response rates across all modes of survey administration have declined, in some cases precipitously (AAPOR, 2017). This drop is consistent with the response rate of mail surveys among groups of health professionals (Cho, Johnson, & Vangeest, 2013). Second, NPs in non–primary care adult settings may have been less likely to respond to the survey because it may have been outside their scope of practice. In addition, the response rate may reflect a lack of familiarity with lung cancer screening guidelines. Finally, the lack of financial incentive for survey completion may have played a role.
According to screening guideline adherence conceptual framework, knowledge, attitudes, and behaviors affect NPs’ ability to execute recommendations. Overall, this study revealed that knowledge and attitudes about lung cancer screening among a majority of NPs was suboptimal. Although the NPs were familiar with the existence of the USPSTF guideline, a minority of responders (35%) selected the correct screening strategy for a variety of patient scenarios. Clinical behaviors and practice patterns lagged behind their knowledge. Moreover, most NPs had not ordered an LDCT scan in the previous 12 months. Very few were familiar with the Medicare billing code used for SDM. The NPs spoke openly about their patients’ financial situations and competing health care demands. Although the initial screening would be free for many patients, additional scans and procedures together with the required deductibles would increase cost and inconvenience. The direct and indirect costs related to transportation and inevitable time off from work were sufficiently burdensome to lead patients and their providers to avoid the situation. Substantial external barriers that thwarted provider referrals included workload, lack of institutional administrative and electronic support systems–based solutions, availability of educational materials to facilitate brief SDM encounters, marketing materials to help identify high-risk patients and facilitate the referral process, and follow-up clinical resources for patient surveillance and treatment referrals.
Although most NPs described wanting to be involved in SDM regarding lung cancer screening, many reported not initiating conversations about the risks and benefits of LDCT screening. Barriers exist that prevent SDM engagement. Time is an influential factor related to SDM. When asked about the average number of patients seen per day, 24% of the NPs reported more than than 20 patients per day (Table 1). When the SDM process took more than 8 minutes as opposed to less than 3 minutes, the commitment to engaging in it decreased substantially (from 92% to 37%). Further documentation is needed on the role of the NP in recommending cancer screening and engaging in formal SDM for LDCT screening.
In addition to its mixed-methodology design, a strength of this study is that it is the first survey targeting NPs since the publication of the NLST results (NLST Research Team et al., 2011), the release of the screening recommendations from the USPSTF in 2013, and the CMS decision to provide coverage. As providers of care for most patients, all primary care providers play an essential role in the early detection of lung cancer.
Several limitations in our study should be noted. The response rate by this large sample of NPs was not optimal and limits the generalizability of our findings. A very high proportion of the sample (n = 305; 80%) agreed to the qualitative interview, which garnered them a $50 gift card in exchange for their participation—suggesting the importance of the “thank you” gift. Providing a gift for survey completion would likely have increased our analytic sample size. Of interest, approximately 69% of participants (n = 254) provide care to a primarily younger (<55-year-old) or mixed-age population of patients. This may have been a key factor in the lower survey response rate meaning that perhaps the survey was not relevant to their major focus of their practice with patients. Primary care providers are responsible for keeping abreast of a large volume of recommendations for screening services. It is understandable, therefore, that primary care providers prioritize the integration of frequently used guidelines for their patient populations. This lack of familiarity may affect survey participation and the actual responses.
Conclusions
This study illustrates the strengths of using a conceptual framework and a mixed-methods approach to study clinical guideline uptake among NPs in primary care settings. The explanatory sequential design allowed for a much deeper interpretation and expanded view of the barriers that emerged. This study helped foster greater understanding of the complexity of patient-related barriers, the difficulty in changing long-standing practice patterns, and the lack of systems-based solutions in primary care practice environments. Indeed, NPs seemed to welcome the opportunity to share with us the difficult aspects of their primary care practice as it relates to the translation and adoption of a cancer screening guideline. If this conclusion is correct, then the findings of this study have serious implications for the uptake of clinical guidelines for cancer screening.
In this study, the barriers far outweighed the facilitators. Approving and disseminating clinical practice guidelines and authorizing health insurance reimbursement are not enough. We agree with Haas et al. (2016) that it is imperative for guideline-issuing organizations to work with patient and provider stakeholder groups to ensure that stakeholder concerns are addressed. It cannot be overstated that lung cancer is the most common cancer and leading cause of death in men and women (Smith et al., 2017). We have the knowledge and technological capabilities to significantly reduce this burden, but we must be realistic that greater progress will not be made until a culture change occurs in which the early detection of cancer has greater value for policy makers, insurers, providers, and patients.
Acknowledgement: The authors would like to express their appreciation to Dana D. DeHart, PhD, Research Professor & Assistant Dean for Research, College of Social Work, University of South Carolina, Columbia, SC 29208, for reviewing this manuscript prior to submission.
Authors' contributions: Karen Kane McDonnell, Amy C. Dievendorf, Lauren Blew, Deborah Warden, Samira Khan, Erica Sercy, and Jan M. Eberth were involved in the design, implementation, and data management plan for the study, as well as in writing and reviewing this manuscript. Karen Kane McDonnell, Robin Dawson Estrada, and James W. Hardin conducted the quantitative and qualitative data analyses. All authors reviewed the final manuscript.
Funding: This work was supported by a University of South Carolina College of Nursing Preparatory Research Work Grant, an Office of Research Magellan Scholar Award, and an American Cancer Society Institutional Research Grant (124275-IRG-13-043-01-IRG).
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