Restructuring Lung Cancer Care to Accelerate Diagnosis and Treatment in Patients Vulnerable to Healthcare Disparities Using an Innovative Care Model

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MethodsX 11 (2023) 102338
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MethodsX
journal homepage: www.elsevier.com/locate/methodsx
Restructuring lung cancer care to accelerate diagnosis and
treatment in patients vulnerable to healthcare disparities using an
innovative care model
Jessica Copeland
a , ∗
, Eliza Neal
a
, Will Phillips
a
, Sophie Hoerberth
b
,
Christopher Lathan
c
, Jessica Donington
d
, Yolonda Colson
a
a
Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
b
Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
c
Division of Medical Oncology, Department of Medicine, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
d
Division of Thoracic Surgery, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
          
Method name:
Lung Cancer Strategist Program (care model
developed) based o of FastTrack (method
used to develop the care model)
Keywords:
Non-small cell lung cancer
Integrative multidisciplinary care
Healthcare disparities
Social determinants of health
Novel healthcare delivery model
       
The diagnosis and treatment of lung cancer is challenged by complex diagnostic pathways and
fragmented care that can lead to disparities for vulnerable patients. Our model involved a multi-
institutional, multidisciplinary conference to address the complexity of lung cancer care in vul-
nerable patient populations. The conference was conducted using a process adapted from the
problem-solving method entitled FastTrack, pioneered by General Electric. Conference attendees
established critical social determinants of health specic to lung cancer and designed a practical
care model to accelerate diagnosis and treatment in this population. The resulting care delivery
model, the Lung Cancer Strategist Program (LCSP), was led by a lung cancer trained advanced
practice provider (APP) to expedite diagnosis, surgical and oncologic consultation, and treatment
of a suspicious lung nodule. We compared the timeliness of care, care eciency, and oncologic
outcomes in 100 LCSP patients and 100 routine referral patients at the same thoracic surgery
clinic. Patient triage through our integrated care model transitioned initial referral evaluation to
a lung cancer trained APP to coordinate multidisciplinary patient-centered care that was highly
individualized and signicantly reduced the time to diagnosis and treatment among vulnerable
patients at high-risk for treatment delay due to healthcare disparities.
• To develop the Lung Cancer Strategist Program care model, we used a three-step ( Design,
Meeting, and Culmination ), team-based, problem-solving process entitled FastTrack.
• An advantage of FastTrack is its ability to overcome barriers embedded within hierarchal and
institutional social systems, empowering those closest to the relevant issue to propose and
enact meaningful change.
• Under this framework, we engaged a diverse eld of experts to assess systemic barriers in lung
cancer care and design an innovative care pathway to improve the timeliness and eciency
of lung cancer care in patients at risk for healthcare disparities.
∗ Corresponding author.
E-mail address: jcopeland@hsph.harvard.edu (J. Copeland) .
https://doi.org/10.1016/j.mex.2023.102338
Received 11 May 2023; Accepted 19 August 2023
Available online 24 August 2023
2215-0161/© 2023 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license
( http://creativecommons.org/licenses/by/4.0/ )

J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
Specications Table
Subject Area: Medicine and Dentistry
More specic subject area: Healthcare Delivery
Method name: Lung Cancer Strategist Program (care model developed) based o of FastTrack (method used to develop the care
model)
Name and reference of original method: FastTrack (formerly Workout), pioneered by General Electric, was applied to facilitate problem-solving across a
multidisciplinary panel of experts to result in the design and implementation of a novel healthcare delivery model.
References and Applications of FastTrack:
Joseph, J. & Ocasio, W. Architecture, attention, and adaptation in the multi-business rm: General Electric from
1951 to 2001. Strategic Management Journal vol. 33 (2012).
Henderson, K. M. & Evans, J. R. Successful implementation of Six Sigma: benchmarking General Electric
Company. Benchmarking: An International Journal 7, (2000).
Ngoie, O. M. General Electric case study - case study. DBA Program (2014).
Clinton Health Access Initiative. Eliminating Mother-to-Child Transmission of HIV: CHAI’s "across the cascade"
approach. 2011;
http://www.clintonhealthaccess.org/les/CHAI-eMTCT-fact-sheet-nov-2011.pdf .
Schaninger Jr WS, Harris SG, Niebuhr RE. Adapting General Electric’s Workout for Use in Other Organizations: A
Template. Management 1999;2(1):99.
Resource availability: Not applicable
Introduction
Lung cancer is the leading cause of cancer-related death in the world killing three times more Americans than any other cancer
[ 1 , 2 ]. The ve-year survival rate for patients with lung cancer is approximately 15%, drastically lower than the 64% survival rate of
colon, 89% of breast, and 99% of prostate cancers [ 2 , 3 ]. Although these dierences in survival rates are daunting, survival nearly
quadruples when lung cancer is diagnosed and treated at an early stage, with a 5-year survival rate of 60–70% [4] .
Like many diseases, lung cancer survival is impacted by dierences in accessibility and quality of care [5–9] . Data show that for
vulnerable populations the incidence, prevalence and mortality rates for lung cancer are signicantly higher compared to the general
population [ 8 , 10 , 11 ]. Health disparities in lung cancer are multifactorial and aect all aspects of care, from screening and diagnosis,
to treatment, survivorship, and end of life care. Social determinates of health that have emerged as key facilitators of health disparities
include: cultural and biologic dierences, systemic and structural impacts of race and class, inaccessibility to care and communication
style [ 7 , 12 , 13 ]. Strikingly, these disparities still persist in equal access healthcare systems such as Medicare [14–19] .
The recent extension of lung cancer screening guidelines by the USPSTF is expected to more than double the number of Americans
that qualify for lung cancer screening which will further compound the disparities and ineciencies associated with lung cancer care
[20] . Currently, 2 million Americans are diagnosed with a new pulmonary nodule annually [21] , and an estimated 80,000 require
surgical evaluation for malignant potential [22] . Although the inclusion of patients with lower smoking history signicantly increases
the numbers of minorities and women eligible for screening, the challenge for medical centers to provide high-quality, equitable lung
cancer care to disadvantaged socioeconomic populations will be magnied by the increasing demand for limited oncology services
and high costs associated with providing highly specialized and resource-intensive services.
Accordingly, it is crucial to implement novel care pathways that result in timely delivery of specialized thoracic oncologic care and
are specically constructed for populations that are vulnerable to having limited access to health care or encounter signicant barriers
to care. Novel pathways must work to streamline diagnostic and treatment pathways to prevent overloading of the system, provide
diagnosis and treatment at the earliest stages of disease, and alleviate the impact social determinants of health have on lung cancer
survival rates to assure equitable access to curative therapies. Patient navigation has emerged as a sustainable solution to minimize
barriers in healthcare delivery and improve outcomes in vulnerable patients at high-risk for healthcare disparities. Such programs
have proven helpful for vulnerable patients with breast, cervical, colorectal, and prostate cancer resulting in reduced patient anxiety,
increased rates of cancer screening, and improved clinical outcomes through delivery of timely care [ 9 , 11 , 23–27 ]. However, patient
navigation requires that the care pathways be relatively established and non-variable which is often not the case in lung cancer.
The optimal clinical approach for a newly identied suspicious pulmonary nodule frequently involves complex decision making and
diagnostic work-up that remains subject to provider interpretation, resulting in cancer care that is commonly delivered through
multiple disorganized, clinical pathways.
To address these critical issues The Connors Center for Women’s Health and Gender and the Division of Thoracic Surgery within
Brigham and Women’s Hospital and the Division of Medical Oncology at the Dana Farber Cancer Institute (DFCI) held a two-day con-
ference centered on the design and implementation of a novel strategic care model to streamline the triage, diagnosis, and treatment
of lung cancer in patients at high-risk for healthcare disparities. The objective was to listen to patients, caregivers, social organiza-
tions, healthcare providers, and government agencies to identify the key social determinants of health that impede care across the
full spectrum of lung cancer and to implement a system that streamlines risk assessment, detection, diagnosis, and treatment [ 13 , 28 ].
Results from the conference yielded the design of the Lung Cancer Strategist Program (LCSP), a novel integrated care model that
incorporated a single point of contact for expedited patient triage, risk assessment, and formulation of a multidisciplinary diagnostic
and treatment plan. The ecacy of the LCSP to provide care to patients with non-small cell lung cancer (NSCLC) at high-risk for
healthcare disparities was assessed in terms of timeliness of care delivery, care eciency, and treatment adherence.
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J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
Conference approach
The Innovative Clinical Pathways in Lung Cancer Care for Vulnerable Populations Conference was a two-day, multidisciplinary event
involving 17 institutions and 63 stakeholders and leaders in the eld of thoracic oncology funded by the Agency for Healthcare and
Research Quality (AHRQ). The conference focused on the dissemination and implementation of evidence-based guidelines and care
tools related to the full spectrum of NSCLC-care in high-risk populations. To develop the LCSP, conference organizers used a three-step
( Design, Meeting, and Culmination ), team-based, problem-solving process entitled “FastTrack ” pioneered by General Electric [29–31] .
The FastTrack process has been successfully validated in the public health arena in initiatives such as the Clinton Foundation Program
to reduce mother-to-child-transmission rates of HIV [28] . A major advantage of FastTrack is the demonstrated ability to overcome
barriers embedded within hierarchal and institutional social systems. FastTrack empowers those closest to the relevant issue to
propose and enact meaningful change [ 29 , 30 ]. Under this framework, we engaged key stakeholders in the design and implementation
of eective solutions to improve the accessibility of lung cancer care and patient outcomes.
FastTrack problem solving approach & outcomes
Design stage
Prior to the conference, a Steering Committee, consisting of a multidisciplinary panel of leaders in their respective elds, gathered
to organize and construct a conference that would produce practical and actionable results. The Steering Committee consisted of a
diverse group of 13 members including: thoracic surgeons, medical oncologists, pulmonologists, primary care physicians, geriatricians,
patient advocates, healthcare business leaders, and policy experts. Ultimately, the diversity of the Steering Committee was considered
the strength and backbone for the success of the conference in achieving its primary objective.
Once formed, the Steering Committee met monthly to formulate the most relevant issues for discussion at the conference, key
attendees critical to the conference’s success, and structure the conference to assure the creation of a care pathway that was widely
applicable to dierent clinical settings and among dierent vulnerable patient populations. Additionally, each Steering Committee
member identied: (1) conference goals and expectations, (2) perspectives on barriers to successful lung cancer care and treatment, (3)
ideas on how to improve lung cancer care and treatment from their respective role in lung cancer care, (4) experiences providing lung
cancer care and/or working with vulnerable populations, and (5) key stakeholders, including patients, to recruit to the invitation-only
conference for the design of a novel care pathway.
The Steering Committee’s framework for the conference emphasized three pivotal points along the spectrum of lung cancer care
where patient barriers were most likely to be magnied: 1) Clinical Barriers, 2) Community Barriers, and 3) Infrastructural Barriers.
Within this framework, six areas of improvement were identied as essential components in establishing an eective and sustainable
patient navigation pathway: 1) Care Coordination and Communication Solutions, 2) Patient Follow-Up Solutions, 3) Access Manage-
ment Solutions, 4) Quality Measure Solutions, 5) Social Support and Service Solutions, and 6) Community and Patient Education
Solutions ( Fig. 1 ).
Fig. 1. Integrating barriers (Venn Diagram) and solutions (Outer Circle) to common failure points across the spectrum of lung cancer care.
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J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
Fig. 2. Current status of lung cancer care, lung cancer is one of the most complex clinical problems in the healthcare system. Patients can enter
through multiple avenues and have multiple providers involved in the diagnosis, treatment, and maintenance of their disease.
Based on this framework, the Steering Committee identied and recruited participants equipped to provide a broad range of
perspectives and expertise in thoracic oncology and healthcare disparities. The nal group of conference participants represented a
cross-section of key stakeholders across a range of disciplines. In total, 63 participants attended the conference representing 17 inde-
pendent healthcare institutions from 6 states and included physicians (surgeons, oncologists, pulmonologists, radiologists, internists),
surgical and oncology nurses, clinical support sta, healthcare administrators, policymakers, patient advocates, as well as patients
and their families.
Meeting stage
The conference was divided into two sections: an idea exchange and data gathering workshop followed by a care model design and
implementation workshop. To start the conference, attendees engaged in a key discussion on how lung cancer care is representative
of current healthcare failures since it is dicult to navigate, manage, and organize timely care from the perspective of the patient,
practitioner, and even the healthcare system itself. Patients with lung cancer enter the healthcare system through multiple avenues
and with a wide range of clinical presentations, resulting in multiple providers with responsibility to coordinate care throughout
diagnosis, treatment, and disease maintenance. By collectively analyzing multiple clinical scenarios and the care pathways it became
evident that lung cancer is one of the most intricate yet fragmented clinical problems in the healthcare system ( Fig. 2 ). Thus, providing
a simplied and ecient lung cancer care model is an urgent healthcare imperative.
During the idea exchange and data gathering workshop, participants were divided into teams of 8–10. Each team was facilitated
by a Steering Committee member to identify health disparities and failures in care along the spectrum of lung cancer management.
To maximize the identication of barriers, participants were organized into one of three barrier groups (Clinical, Infrastructural, or
Community) by combining similar areas of expertise (Caregiver, Patient Advocate & Support, and Patient) to allow for a representative
voice to emerge from each team ( Table 1 ). This allowed us to identify the most signicant barriers that were essential to address in
the design of a novel patient care pathway. During this workshop common themes arose from all groups, including: fragmentation
of care, poor communication, cultural dierences, and accessibility to care. Additionally, each group highlighted the disease itself
as being an inherent barrier- its current clinical complexity, the intensity of the treatments, and the urgency of intervention make
it particularly dicult to manage, navigate, and cure. These barriers are graphically displayed in the shbone diagram ( Fig. 3 ),
outlining the key clinical factors that increase the impact of health care disparity in the treatment of lung cancer.
Insights from the clinical team
The clinical team observed that one of the central breakdowns in the spectrum of lung cancer care was the lack of patients as
integral members of the care team. Although providers voiced openness and desire for shared decision-making, physicians found it
dicult to explain the complexities and nuances of lung cancer without overwhelming patients. This issue was further exacerbated by
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J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
Table 1
Conference teams divided into three groups to address specic type of barriers (Clinical, Infrastructural, Community) by combining similar areas of
expertise (Caregiver, Patient Advocate & Support, and Patient).
CLINICAL TEAM: INFRASTRUCTURAL TEAM: COMMUNITY TEAM:
Primary Care Providers,
Medical Oncologists,
Radiation Oncologists,
Pulmonologists,
Thoracic Surgeons,
Nursing Sta,
Pain Management Specialists,
Clinical Support Sta
Patient Care Coordinators,
Payment and Financial Care Coordinators,
Access Management Sta,
Quality Improvement Sta,
Health Information Technology Support
Patient Care Services,
Patient Navigators,
Smoking Cessation Counselors,
Social Workers,
Patient Advocates,
Public Health Experts,
Patients and Family Members
Fig. 3. Fishbone diagram outlining key factors that increase healthcare disparities along the spectrum of lung cancer care.
patients interacting and receiving advice from multiple providers during separate sessions with each provider speaking about dierent
treatment options in their respective eld. Further, patients did not consistently perceive a welcomeness to participate in their care
plan. Specically, patients voiced that physicians did not always seem to know how to elicit or incorporate patient input. Therefore,
the physician’s diculty in oering support and hope, being a team leader, and still being able to convey all the information needed
to help the patient make an informed decision emerged as a prominent barrier. This issue is growing in importance as physicians
experience greater time constraints and increased productivity targets.
Insights from the infrastructural team
The infrastructural team identied three major solutions and barriers consisting of: 1) Coordination of care to address the inherent
complexity and fragmentation of lung cancer care; 2) Recognition that access and nancial barriers are not isolated to a patient’s
insurance status and the need for upfront, individualized, social service assessment for potential barriers to care; and 3) Creation
of a care delivery model where education and empowerment are built into the infrastructure. Additional factors they proposed to
incorporate into the design of the care model were to increase the knowledge within the community about cancer risk, help patients
make well-informed choices, and address emotional needs intrinsic to the fear and stigma that often accompany lung cancer. They
also focused on the need for building a model that allowed patients to logistically and practically get the services and support needed
throughout all phases of treatment (spanning home-, community-, hospital- and hospice-based care).
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J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
Table 2
List of barriers and solutions to lung cancer care and treatment.
Clinical Barriers:
Treatment: multiple appointments, procedures, and intensive and complex
care.
Coordination of care : lack of dened treatment process, designated care
coordination, care coordinator, and communication.
Care Coordination:
Patient is a pivotal team member.
Designated care coordinator.
Centralized care coordination.
After visit summaries.
Curbside consults for quick patient referrals.
Quality Measures:
Wait time intervals for consultative, diagnostic, and treatment services.
Patient satisfaction and quality of life metrics.
Institutional costs.
Evaluation of current care models.
Community Barriers:
Patient perception(s): mistrust, cultural and language barriers, fear, stigma,
and denial.
Patient experience(s): lack of sensitivity and communication skills among
providers.
Patient limitation(s) : transportation, child care, employment, income,
health literacy, education, socioeconomic barriers, and life-altering
situations.
Social Support Services:
Health literacy assessment.
Patient specic social support.
Caregiver support.
Psychosocial screening.
Survivorship plans.
Community and Patient Education:
Patient education: prevention and importance of lung cancer screening.
Provider education: knowledge and readily available information on
community support services.
Infrastructural Barriers:
Insurance: coverage and benets.
Smoking: screening and smoking cessation programs.
Health care system: lack of connection between hospitals, providers, and
community resources.
Access Management:
Patient navigation system.
Information technology resources (virtual visits)
Patient Follow-Up:
Provider scripts.
Closed loop communication.
Information technology resources (mobile applications, patient registries,
scheduling and reminder systems, and computerized decision support).
Insights from the community team
The community team highlighted barriers in three major areas: fragmentation of care, communication, and accessibility. The
cohort observed fragmentation of care as a cause for unnecessary delays in diagnosis, the practice of multiple appointments to
establish a care plan, and communication breakdown. They also voiced that while physicians provided resources for patient care,
knowledge of resources within the community was not universal, and thus community support was also inconsistent and disparate.
Community groups identied issues of fear, stigma, and health literacy as chief barriers in communication. Barriers created by access
were expanded from transportation and income to include hardships imposed by loss of work due to multiple appointments, challenges
of treatment, and complicated recoveries.
Culmination stage
From these fundamental observations by each team, the Steering Committee developed a comprehensive but focused list of so-
lutions to address each of the three key barriers (Clinical, Infrastructural, and Community), crucial in the implementation of a new
clinical care model ( Table 2 ). These solutions were constructed to also address another major conclusion of the conference, that
patients at high-risk for healthcare disparities experience increased fragmentation of care, poor communication, and limited access.
Solutions to successfully overcoming these barriers were concentrated on (1) coordinating care and improving communication across
practitioners, (2) upfront social and community support assessment, and (3) establishing an integrative, multidisciplinary care team
personalized to the patient.
Centralization of care and restructuring initial patient assessment
Given the complexity of lung cancer as a disease and of the fragmentation of care involved, the proposed solution of nearly all
teams focused on a central gure whose role was to lead care coordination and establish a paradigm where the patient and primary
care provider (PCP) are key members of the care team. Additionally, restructuring the traditional care pathway so that the initial
consultation process for a suspicious pulmonary nodule was transitioned to the care coordinator was identied as fundamental in
facilitating integrative care in terms of oncologic, surgical, and social service specialists and providing a multidisciplinary, patient-
centered, treatment plan in a streamlined manner.
Developing a pathway centered on coordination of care highlighted the critical need for improved communication and support
during key transitions in care (pre-diagnosis to diagnosis, surgical care to chemoradiation or vice versa, or from community to hospital
to hospice care). Focusing on these transitions is crucial as this is where patient loss in the healthcare system is highest. Thus, it was
crucial that our model identied a single contact person as the focal point for patients, providers, and the multidisciplinary care
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J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
team. This would allow the care coordinator to serve as a conduit for the delivery of comprehensive clinical care in an individualized
fashion.
By coordinating care through a central point, a multidisciplinary team of specialists could then establish an integrative, streamlined
and clinically appropriate pathway for diagnosis and treatment that could in turn, be executed by the central coordinator. This
paradigm was observed to have the potential to minimize patient time, eort, and risk while maximizing cost eciency and diagnostic
accuracy. Given the level of medical knowledge required for this responsibility and coordination, it was concluded that central
coordination would require an advanced practice provider (APP) with expertise in lung cancer care to strategically execute the
diagnostic care plan. Since a critical challenge in integrating a diagnostic and treatment pathway for lung cancer is founded on multiple
pathways to diagnosis, centralization and early triage by thoracic trained specialists were deemed critical, as was the connection
between patient and community provider in achieving improved navigation after a personalized plan was established. Accordingly,
the role of referral pathways to specialized care and streamlined individualized diagnostic and care plans established and facilitated
by an APP, were implemented as our primary intervention in our care model, the Lung Cancer Strategist Pathway (LCSP) and pilot
study.
LCSP care model implementation & validation
LCSP approach
To address the ineciencies and disparities specic to lung cancer care, we designed and implemented an integrated, patient
centered, model of care, the Lung Cancer Strategist Program. LCSP was designed to minimize diagnostic redundancy, streamline
management decisions for suspicious nodules, and expedite curative therapy for lung cancer patients at high-risk for treatment delay.
Team and workflow
The LCSP approach was centered on coordinated evaluation of a suspicious lung lesion through a lung cancer-trained APP des-
ignated as the clinical-strategist (CS). In practice, the CS reviewed the patient’s medical record following referral and presented the
patient to a specialist panel to develop a customized evaluation strategy for each patient and ordered any necessary testing prior to
the patient’s rst visit. The patient was evaluated at their rst clinic visit by their Personalized Care Team (PCT), which was assem-
bled by the CS and consisted of the appropriate oncologic, surgical, and social support specialists who reviewed results, discussed
diagnosis, and implemented a multidisciplinary treatment plan ( Fig. 4 ). This is distinctly dierent than coordination and navigation
of the patient from provider to test and then to subsequent provider, rather this is the design of a strategic, ecient plan for the rapid
diagnosis and treatment of lung cancer.
Lung cancer strategist program an integrative care model strategy
The LCSP consisted of a multidisciplinary thoracic oncology team led by a lung cancer trained advanced practice provider and
thoracic surgeon in consultation with oncology specialists. The rationale for pairing the APP with a thoracic surgeon rather than
a medical or radiation oncologist is that surgical assessment is paramount in curative strategies and often in the diagnosis of lung
cancer. Biopsy of a lesion when surgical resection is already warranted poses an unnecessary delay and risk. Therefore, the most
expeditious means to curative resection for a highly suspicious nodule or a nodule which changes during surveillance is to have the
surgeon involved in the initial assessment. This has the added benet of allowing triage to radiation oncology (or other members in the
PCT) for treatment or surveillance if the patient is not a surgical candidate, thus further decreasing delay for non-surgical treatments.
We hypothesized that expedited diagnosis and treatment of a suspicious lung nodule could be achieved in vulnerable patients at
high-risk for treatment delay when managed within the LCSP care model compared to patients who underwent routine referral at
the same thoracic surgery clinic. Our model aimed to (1) restructure the initial consultation process after a suspicious pulmonary
nodule was identied by transitioning the initial referral evaluation from specialist providers to APPs with lung cancer expertise, (2)
incorporate oncologic and surgical specialists to create a multidisciplinary, patient-centered, treatment plan in a streamlined manner
and (3) accelerate the timeliness of care and decrease procedures and care transitions in a vulnerable patient population at high-risk
for experiencing treatment delay due to healthcare disparities amid fragmented, disorganized care.
Patients with a suspicious lung nding that were deemed high-risk for treatment delay, based on vulnerability characteristics, were
prospectively accrued to the LCSP or to routine referral cohort. Lung nodules were risk stratied and identied as suspicious based on
the Fleischner criteria. Vulnerability characteristics were dened based on patient factors identied in the literature associated with
treatment delays including: psychiatric disorder, advanced age ( > 80 years old), low socioeconomic status, language barrier, physical
disability, transportation limitation, polysubstance abuse, and caregiver responsibilities ( Fig. 5 ) [32–39] . History of polysubstance
abuse and psychiatric disorders (schizophrenia, bipolar disorder, depressive disorder, and dementia) were documented according
to the pre-existing diagnoses in the medical record. A language barrier was dened as persons with limited English prociency,
transportation barrier as an inaccessibility to a vehicle, physical disability as wheelchair-bound, blindness, deafness, and/or a history
of falls, and low socioeconomic status was dened as those unemployed, uninsured, undomiciled, and/or with Medicaid health
insurance.
Analysis of the rst 100 patients managed in the LCSP versus the routine referral cohort within the same thoracic surgery clinic
was performed. Primary outcome measures were timeliness of care delivery and care eciency. Timeliness of care delivery was
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J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
Fig. 4. Overview and workow of the lung cancer strategist program.
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J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
Fig. 5. Patients were deemed high-risk for treatment delay based on vulnerability characteristics that are represented across the LCSP cohort and
routine referral cohort.
dened as the time interval from an initial suspicious lung nding to work-up, diagnosis, and denitive management plan (i.e., date
of surveillance recommendation or initiation of treatment). Care eciency was assessed by the number of hospital trips, clinicians
seen, and diagnostic studies performed during work-up of the lung lesion. Secondary outcome measures were patient care adherence,
stage at diagnosis, disease-free survival (DFS) and overall survival (OS). Pearson chi-square test was used to compare the percentage of
patients in the LCSP and routine-referral groups. Timeliness of care and care eciency metrics were compared using non-parametric
Mann-Whitney U test. Independent binary proportions were compared using Fisher’s exact test. Statistical analysis was performed
with SPSS 23.0 (IBM Corporation, Armonk, NY). A P value < 0.05 was considered statistically signicant.
Model validation
In this report, we provide our methods for creating the LCSP, a multidisciplinary, patient-centered, integrated care model led by
a lung cancer trained APP to streamline thoracic surgeon and oncologic specialist consultations and accelerate lung cancer diagnosis
and curative therapy by optimizing access to medical care in patients identied as high-risk for treatment delay. In our prospective,
non-randomized, single-center pilot study, the LCSP model signicantly accelerated the time to diagnosis and treatment for patients
with intrathoracic malignancies as well as the eciency of care in patients who are at high-risk for healthcare disparities.
The LCSP was superior in all measures of timeliness of care when compared to U.S. national standards and routine referral through
the same thoracic surgery clinic. Overall, in the LCSP cohort we observed a median 7-day reduction from the time of patient referral
to denitive management plan (12 vs. 19 days; p = 0.001) and 25-day reduction from the time of the initial suspicious nding to
work-up (3 vs. 28 days; p < 0.001) compared to the routine referral cohort. Further, treatment was provided at a median of 28 days
earlier in the LCSP cohort diagnoses with malignancy compared to routine referral (40.5 vs. 68.5 days; p = 0.02). Care eciency was
also improved in the LCSP cohort by reducing healthcare redundancy in the form of hospital visits (4 vs. 6; p = 0.001) and diagnostic
testing (4 vs. 5; p = 0.01) compared to the routine referral cohort, while the number of clinicians seen did not signicantly vary
(1.5 vs. 2; p = 0.08) ( Fig. 6 ). Of the patients diagnosed and treated for NSCLC, there was no signicant dierence observed in clinical
or pathologic stage at diagnosis or modality of treatment across cohorts. However, a higher rate of malignant diagnosis occurred in
the routine referral cohort at 49% compared to the LCSP at 15% ( p < 0.001).
Improvements in timeliness of care delivery were attributed to the clinical strategist being able to provide expert lung cancer
evaluation and act as a central point of contact for patients, referring providers, and oncology specialists. The rates of patient adherence
and retention were similar at 83.3% and 82.9% for the LCSP and routine referral cohorts respectively, even with the LCSP’s higher
incidence of vulnerable features predisposing to care delays and non-adherence. However, the LCSP care adherence rate was superior
to single institution studies reporting rates of 51–65% adherence and retention for patients enrolled in lung cancer screening programs
with systematic policies in place to improve retention [26–27] .
9

J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
Fig. 6. Diagnostic and treatment timeline for the LCSP cohort compared to the routine referral cohort.
However, we recognize this study has several important limitations. It was agreed that randomizing vulnerable patients to a path-
way known to have treatment delays and fragmented care was undesirable and thus our study was a prospective, non-randomized,
and non-blinded. This design impacted the referral patterns of each cohort. First, as referring providers became aware of the LCSP,
patients at high-risk for healthcare disparities were more likely to be referred to the LCSP than the routine referral cohort. Despite,
having a similar source population the routine referral cohort was still less heterogeneous in terms of patients at risk for healthcare
disparities compared to the LCSP. Accordingly, the routine referral cohort potentially underestimates the impact that healthcare
disparities have on the timeliness of routine care. Second, there was a disproportionate number of patients referred to the LCSP by
emergency room physicians instead of primary care physicians. This potentially led to an overestimation of those requiring surveil-
lance and underestimation of those needing treatment in the LCSP cohort. That is, patients referred by primary care physicians have
often already undergone a surveillance period by the primary care physician and are referred once suspicious changes in surveillance
are observed whereas, emergency room physicians are more likely to refer patients based on incidental ndings which are more likely
to be indolent in nature, primarily requiring surveillance.
Still, leveraging a broad range of expertise to systematically assess the social determinants and barriers to lung cancer care to
create a novel healthcare pathway resulted in a signicant improvement in care metrics for lung cancer patients at risk for healthcare
disparities. Specically, the LCSP signicantly accelerated time to work-up, diagnosis, and treatment in a disease with a complex care
pathway and in a patient population at high-risk for experiencing treatment delay.
Conclusions
By restructuring the initial consultation processes and using an integrated care model, providers are able to facilitate shared
decision making between the patient, referring physician, oncology specialists, thoracic surgeon, and social support services from the
time of initial referral. This allows for the delivery of rapid, ecient, patient-centered, multidisciplinary clinical care in populations
at high-risk for healthcare disparities.
Ethics statement
The study was performed in accordance with ethical human research standards, informed consent was obtained by all study
participants and was approved by the institutional review board at Brigham and Women’s Hospital (IRB Number: 2019P000695).
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J. Copeland, E. Neal, W. Phillips et al. MethodsX 11 (2023) 102338
CRediT Author Statement
Jessica Copeland : Methodology, Model Design, Manuscript Preparation; Eliza Neal: Methodology, Reviewing and Editing; Will
Phillips : Data Curation, Validity Testing; Sophie Hofferberth : Reviewing and Editing; Christopher Lathan : Model Design, Method-
ology; Jessica Donington : Model Design, Methodology; Yolonda Colson : Supervision, Editing.
Declaration of Competing Interest
The authors declare that they have no known competing nancial interests or personal relationships that could have appeared to
inuence the work reported in this paper.
Data availability
The authors do not have permission to share data.
Acknowledgments
We would like to thank and acknowledge the Agency for Healthcare and Research Quality for funding The Innovative Clinical
Pathways in Lung Cancer Care for Vulnerable Populations Conference and the collaborative eorts of The Connors Center for Women’s
Health and Gender at Brigham and Women’s Hospital and Dana Farber Cancer Institute in making the conference a success, as well
as all conference participants in providing their expertise.
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