Research Priorities for Interventions to Address Health Disparities in Lung Nodule Management: An Official American Thoracic Society Research Statement

Abstract

Background: Lung nodules are common incidental findings, and timely evaluation is critical to ensure diagnosis of localized-stage and potentially curable lung cancers. Rates of guideline-concordant lung nodule evaluation are low, and the risk of delayed evaluation is higher for minoritized groups. Objectives: To summarize the existing evidence, identify knowledge gaps, and prioritize research questions related to interventions to reduce disparities in lung nodule evaluation. Methods: A multidisciplinary committee was convened to review the evidence and identify key knowledge gaps in four domains: 1) research methodology, 2) patient-level interventions, 3) clinician-level interventions, and 4) health system-level interventions. A modified Delphi approach was used to identify research priorities. Results: Key knowledge gaps included 1) a lack of standardized approaches to identify factors associated with lung nodule management disparities, 2) limited data evaluating the role of social determinants of health on disparities in lung nodule management, 3) a lack of certainty regarding the optimal strategy to improve patient-clinician communication and information transmission and/or retention, and 4) a paucity of information on the impact of patient navigators and culturally trained multidisciplinary teams. Conclusions: This statement outlines a research agenda intended to stimulate high-impact studies of interventions to mitigate disparities in lung nodule evaluation. Research questions were prioritized around the following domains: 1) need for methodologic guidelines for conducting research related to disparities in nodule management, 2) evaluating how social determinants of health influence lung nodule evaluation, 3) studying approaches to improve patient-clinician communication, and 4) evaluating the utility of patient navigators and culturally enriched multidisciplinary teams to reduce disparities.

Keywords: health disparities; health outcomes; lung nodule; pulmonary nodule; research priorities.

Figure 1.

Cascade-of-care framework for identifying potential areas for intervention to reduce disparities in lung nodule evaluation. This figure shows each step of a patient’s path from lung nodule detection through completion of recommended follow-up. Delays of care could potentially be introduced at each step. Interventions to mitigate disparities in lung nodule evaluation might target each of these discrete steps at the patient, clinician, and/or system level. SDOH = social determinants of health.

Figure 2.

Modified Delphi process for identifying research priorities. The chairs and designated moderators drafted research questions related to the four key topic areas. Then, research questions in each topic area were distributed to committee members as a survey with a seven-point Likert scale, with modifications during each subsequent round on the basis of the survey results. For the third and final survey round, committee members were asked to score the questions using a seven-point Likert scale and rank the questions in order of importance within each key topic area. Research questions were prioritized on the basis of the average Likert score from the final survey round, with ties broken by average ranking.