Development and Implementation of the REmote Telehealth User-Reported caNcer Surveillance (RETURNS) Program for Lung Cancer

Although lung cancer is the leading cause of cancer-related deaths in the United States, advances in treatment have greatly increased survivorship. The number of lung cancer patients needing surveillance care has increased faster than for any other cancer. Yet, despite well-established guidelines for surveillance, only one quarter of patients receive recommended surveillance computerized tomography (CT) scans, and nearly 40 percent are lost to followup. Barriers to receiving this care include travel distance to specialty clinics, time away from work, cost, and inconvenience to family members—factors that disproportionately affect minority and low-income populations. Creating the ability to conduct surveillance visits remotely is one strategy for overcoming these barriers.

In previous work, the researchers developed and piloted REmote Telehealth User-Reported caNcer Surveillance (RETURNS) to enable remote lung cancer surveillance care via telehealth. RETURNS collects patient-reported outcomes (PROs) via the Patient-Reported Outcomes Measurement Information System (PROMIS) and allows for asynchronous remote review of these and CT scans done in the community. The system includes a dashboard view that is integrated into the electronic health record. Although the pilot was well received by patients, caregivers, and clinicians, researchers noted the program was not a good fit for all patients and that barriers remained to remote care. This current research will evaluate barriers and facilitators to remote surveillance care and use that information to inform improvements to RETURNS; add a decision aid to the system to help in identifying patients appropriate for remote surveillance care; and implement, evaluate, and test the enhanced system at five diverse hospitals in a pragmatic trial.

The specific aims of the research are as follows:

• Conduct a mixed-methods assessment of patient, caregiver, clinician, and healthcare system barriers and facilitators of remote lung cancer surveillance.
• Create a decision aid to appropriately select patients and contextually adapt and optimize RETURNS.
• Conduct a pragmatic type-1 hybrid trial of RETURNS in five thoracic surgery clinics.

Quantitative and qualitative methods will be used in evaluating barriers and facilitators of remote surveillance to inform enhancements to RETURNS. The focus will be on understanding patient, caregiver, and clinician needs and preferences for this type of care; understanding workflow, communication, and documentation needs during remote surveillance visits; and determining symptoms and outcomes of highest importance to end users following lung cancer surgery. Outcomes in the trial to be evaluated include the effect of RETURNS on adherence to surveillance guidelines, reduction of surveillance disparities, improvements in patient and provider satisfaction, and reduction of patient and healthcare system costs.

Researchers hypothesize that this approach will increase adherence to surveillance guidelines, reduce disparities in surveillance care, increase patient and clinician satisfaction, make care more efficient, and reduce costs, while being grounded in patient-centeredness. In the future, such an approach could be adapted to surveillance of other cancers to broaden the availability of remote surveillance care.