Need: In its first three years, our integrated lung cancer screening and tobacco cessation program performed 1,500 low-dose computed tomography (LDCT) screens in an urban safety-net population of Dallas County. In this region, two social determinants of health (socioeconomic status and healthcare coverage) interconnect with race/ethnicity to underlie disparities in cancer care and outcomes. Despite numerous potential barriers to healthcare and additional challenges related to the COVID pandemic, through provider education and telephone-based patient navigation, our program eventually achieved an LDCT completion rate exceeding 60%. Among this screened population, 65% were under-represented ...
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Need: In its first three years, our integrated lung cancer screening and tobacco cessation program performed 1,500 low-dose computed tomography (LDCT) screens in an urban safety-net population of Dallas County. In this region, two social determinants of health (socioeconomic status and healthcare coverage) interconnect with race/ethnicity to underlie disparities in cancer care and outcomes. Despite numerous potential barriers to healthcare and additional challenges related to the COVID pandemic, through provider education and telephone-based patient navigation, our program eventually achieved an LDCT completion rate exceeding 60%. Among this screened population, 65% were under-represented minorities (URM)—ten times the rate in the National Lung Screening Trial (NLST) upon which LDCT recommendations are based. As anticipated elsewhere in the U.S., we project that recent revisions to lung cancer screening qualifications (minimum age lowered to 50 years, minimum smoking history lowered to 20 pack-years) will most profoundly expand eligibility in Dallas County for URM populations. In particular, this policy change will increase eligibility for individuals residing in a region of South Dallas designated a “medical desert” due to a shortage of primary and specialty care services. Residents in this area have been historically subject to redlining (denial of mortgages and insurance), and they have higher smoking, cancer, and mortality rates. Overall Project Strategy: Guided by findings from the recent Dallas County Community Health Needs Assessment, we will sustain and expand our existing lung cancer screening and tobacco cessation programs—with particular effort in South Dallas—through Parkland Health, the safety net provider in Dallas County (Texas Public Health Region 3). To improve screening adherence and tobacco quit attempts, additional Parkland-based nurse navigators will provide education, logistical support, and psychosocial support through telephone, video, and on-site interactions. Navigators will target Dallas County zip codes with the greatest lung cancer risk and most pronounced health disparities according to the SocioNeeds Index (which incorporates poverty, income, unemployment, occupation, education, and language). Population outreach and education—conducted in concert with Parkland Community Health Workers who live and work in the prioritized geographic area—will be modeled off a successful program of co-created messaging to increase vaccination uptake. Provider education, audit, and feedback will be delivered by a Parkland-based physician champion. Through electronic health record data review, surveys, and patient interviews, we will evaluate the effect of the program on LDCT orders and completions, tobacco cessation referrals and quit rates, and patient-reported outcomes. Specific Goals: Goal 1. In an integrated urban safety-net medical system, sustain and expand lung cancer screening using multimodal navigation, low-dose computed tomography (LDCT), centralized processes, shared decision-making, and evidence-based follow-up. Objective 1. Expand LDCT-based lung cancer screening rate for eligible individuals. Objective 2. Expand navigation to lung cancer screening-eligible individuals. Objective 3. Increase the proportion of referred eligible individuals who complete LDCT. Goal 2. Sustain and expand a tobacco cessation program using evidence-based methods to promote tobacco cessation among LDCT-eligible individuals. Objective 1. Increase referral to evidence-based tobacco cessation programs for LDCT-eligible persons who are current smokers. Objective 2. Increase tobacco cessation rates among LDCT-eligible persons who are current smokers. Significance and Impact: URM and medically underserved populations have higher rates of tobacco use, face higher rates of lung cancer, and experience worse outcomes after diagnosis. Disparities in lung cancer incidence and outcomes are even greater in younger individuals and those with shorter smoking history—a population now included in recently revised lung cancer screening recommendations. Our comprehensive program linking patient and provider education, culturally sensitive navigation services, LDCT-based lung cancer screening, and evidence-based tobacco cessation will continue to have critical impact on a major at-risk and underserved population in Dallas County. Program evaluation will provide data to guide lung cancer screening and tobacco cessation efforts locally, across Texas, and nationwide. Sustainability will be achieved through programmatic and organizational environmental support, funding stability, partnerships, organizational and evaluation capacity, adaptation, communications, and strategic planning. Dissemination will be achieved through Parkland’s national leadership among public health systems, presentations and publications, and the lay press.
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