Academic literature on the topic 'Electronic records Australia Management Case studies'

ObjectivesThe objective of this study was to assess the impact of electronic health records (EHRs) on health outcomes and care of displaced people with chronic health conditions and determine barriers and facilitators to EHR implementation in displaced populations.DesignA systematic review protocol was developed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Systematic Reviews.Data sourcesMEDLINE, Embase, PsycINFO, CINAHL, Health Technology Assessment, Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was searched from inception to 12 April 2021.Eligibility criteria for selected studiesInclusion criteria were original research articles, case reports and descriptions of EHR implementation in populations of displaced people, refugees or asylum seekers with related chronic diseases. Grey literature, reviews and research articles unrelated to chronic diseases or the care of refugees or asylum populations were excluded. Studies were assessed for risk of bias using a modified Cochrane, Newcastle-Ottawa and Joanna Briggs Institute tools.Data extraction and synthesisTwo reviewers independently extracted data from each study using Covidence. Due to heterogeneity across study design and specific outcomes, a meta-analysis was not possible. An inductive thematic analysis was conducted using NVivo V.12 (QSR International, Melbourne, Australia). An inductive analysis was used in order to uncover patterns and themes in the experiences, general outcomes and perceptions of EHR implementation.ResultsA total of 32 studies across nine countries were included: 14 in refugee camps/settlements and 18 in asylum countries. Our analysis suggested that EHRs improve health outcomes for chronic diseases by increasing provider adherence to guidelines or treatment algorithms, monitoring of disease indicators, patient counselling and patient adherence. In asylum countries, EHRs resource allocation to direct clinical care and public health services, as well as screening efforts. EHR implementation was facilitated by their adaptability and ability to integrate into management systems. However, barriers to EHR development, deployment and data analysis were identified in refugee settings.ConclusionOur results suggest that well-designed and integrated EHRs can be a powerful tool to improve healthcare systems and chronic disease outcomes in refugee settings. However, attention should be paid to the common barriers and facilitating actions that we have identified such as utilising a user-centred design. By implementing adaptable EHR solutions, health systems can be strengthened, providers better supported and the health of refugees improved.

summary Diagnostic and therapeutic procedures associated with cardiology are heavily supported by diagnostic imaging technology. The management of such images, including radiographs, echocardiography examinations and cardiac angiography studies, requires a suitable means of handling the data. A number of manufacturers are now offering picture archiving and communication systems (PACS) and telecardiology options. These could greatly improve the efficiency of data management for cardiac examinations, including linkage to radiology and hospital information systems and electronic patient records. A barrier to the implementation of cardiac PACS has been the relatively high capital cost. There have also been technical difficulties in implementing a suitable interface. Historical problems have included ‘turf wars’ between different specialist groups and a reluctance to shift from well established practice patterns. Early cooperative work between radiologists and cardiologists in the development of coronary arteriography has been replaced by contention between cardiologists, radiologists and vascular surgeons, often driven by economic considerations rather than the needs of the patient. At this stage, cardiac PACS and telecardiology have great potential for improving the coordinated care of cardiac patients in Australia.

Abstract Background Phlegmonous Crohn’s disease (CD) is a complication of penetrating disease where traditional management was surgical. There are a paucity of studies evaluating its medical management. The aim of our single-centre, retrospective case series was to evaluate the efficacy and safety of anti-TNF therapy in managing phlegmonous CD. Methods Cases were identified through searching patient records for CT, MRI and intestinal ultrasound reports containing the words “Crohn’s” and “phlegmon”. Patients were included if found to have CD-related phlegmon subsequently started on anti-TNF. Patients were excluded if they were already on an anti-TNF at diagnosis, or underwent surgery prior to starting anti-TNF. Electronic review of patient records was undertaken to determine demographics, current medication, length of disease and surgery. Results Of the 66 cases identified, 11 fulfilled inclusion criteria. 2 cases required surgery at 38 and 197 days post-phlegmon diagnosis, both of which had earlier ceased anti-TNF due to failed trial and severe depression respectively. 4 patients discontinued anti-TNF during follow up: 1 experienced severe anaphylaxis, 1 failed anti-TNF trial, and 2 ceased due to personal preference (severe depression, concern about adverse effects). 8 of 10 had complete resolution of the phlegmon with 1 patient awaiting imaging 6 months post-phlegmon diagnosis. Conclusion 9 of 11 of our patient cohort avoided surgery after starting anti-TNF therapy for phlegmonous CD, out to a median follow up of 20 months. Our findings suggest anti-TNFs are generally well tolerated, and early commencement may be effective in preventing surgical intervention.

Objective Internationally, there is growing interest in the applicability of visual management in healthcare, although little is known about the extent of its effectiveness. In the past 5 years technical advances have permitted the integration of all relevant data into a singular display that can improve staff efficiency, accelerate decisions, streamline workflow processes and reduce oversights and errors in clinical practice. The aim of the case study is to describe the features and application of electronic patient journey boards (EPJBs) as an enabler to accelerate patient flow that has been demonstrated and evaluated in Queensland Health hospitals. Methods In 2012 and 2013 we collected ward-specific data that was sourced from the Queensland Hospital Admitted Patient Data Collection, determining the top 10 overnight diagnostic-related groups (DRGs) for each ward participating in the pilots. The Statistical Output Unit within Queensland Health then provided data and analysis on the ALOS for each of these DRGs for the period following an EPJB installation, along with the ALOS for the same DRGs for the corresponding period in the previous year. Results Patient length of stay reduced and display of estimated discharge dates improved with the introduction of EPJBs along with improved communication and information management resulting in time savings from 20 min per staff member per shift to 2.5 h per ward a day. Conclusion Queensland and South Australian Health systems have succeeded in ‘making the hospital patient journey visible’ through an innovative combination of information management and prominent display of key information related to patient care portrayed on large liquid crystal display (LCD) screens in hospital wards. What is known about the topic? No published studies have explored health services developing, piloting and evaluating Electronic Patient Journey Boards in a variety of clinical settings. What does this paper add? Until recently, paper-based health records and scheduled meetings were the only way for healthcare staff to communicate information to one another. In practice, this means that information vital to patient care is infrequently communicated between team members, is recorded in different places and in different ways, and is heavily reliant on care providers seeking out the information they need to perform effectively in their role. What are the implications for practitioners? This paper can be beneficial for managers and decision-makers of all healthcare organisations when considering streamlining a patients’ journey through a hospital with the assistance of visual management tools.

Background Artificial intelligence (AI) has shown promising results in various fields of medicine. It has the potential to facilitate shared decision making (SDM). However, there is no comprehensive mapping of how AI may be used for SDM. Objective We aimed to identify and evaluate published studies that have tested or implemented AI to facilitate SDM. Methods We performed a scoping review informed by the methodological framework proposed by Levac et al, modifications to the original Arksey and O'Malley framework of a scoping review, and the Joanna Briggs Institute scoping review framework. We reported our results based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) reporting guideline. At the identification stage, an information specialist performed a comprehensive search of 6 electronic databases from their inception to May 2021. The inclusion criteria were: all populations; all AI interventions that were used to facilitate SDM, and if the AI intervention was not used for the decision-making point in SDM, it was excluded; any outcome related to patients, health care providers, or health care systems; studies in any health care setting, only studies published in the English language, and all study types. Overall, 2 reviewers independently performed the study selection process and extracted data. Any disagreements were resolved by a third reviewer. A descriptive analysis was performed. Results The search process yielded 1445 records. After removing duplicates, 894 documents were screened, and 6 peer-reviewed publications met our inclusion criteria. Overall, 2 of them were conducted in North America, 2 in Europe, 1 in Australia, and 1 in Asia. Most articles were published after 2017. Overall, 3 articles focused on primary care, and 3 articles focused on secondary care. All studies used machine learning methods. Moreover, 3 articles included health care providers in the validation stage of the AI intervention, and 1 article included both health care providers and patients in clinical validation, but none of the articles included health care providers or patients in the design and development of the AI intervention. All used AI to support SDM by providing clinical recommendations or predictions. Conclusions Evidence of the use of AI in SDM is in its infancy. We found AI supporting SDM in similar ways across the included articles. We observed a lack of emphasis on patients’ values and preferences, as well as poor reporting of AI interventions, resulting in a lack of clarity about different aspects. Little effort was made to address the topics of explainability of AI interventions and to include end-users in the design and development of the interventions. Further efforts are required to strengthen and standardize the use of AI in different steps of SDM and to evaluate its impact on various decisions, populations, and settings.

Background Over the past decades, the deficient provision of evidence-based interventions for the prevention and treatment of mental health problems has become a global challenge across health care systems. In view of the ongoing diffusion of new media and mobile technologies into everyday life, Web-delivered electronic mental health (e-mental health) treatment services have been suggested to expand the access to professional help. However, the large-scale dissemination and adoption of innovative e-mental health services is progressing slowly. This discrepancy between potential and actual impact in public health makes it essential to explore public acceptability of e-mental health treatment services across health care systems. Objective This scoping review aimed to identify and evaluate recent empirical evidence for public acceptability, service preferences, and attitudes toward e-mental health treatments. On the basis of both frameworks for technology adoption and previous research, we defined (1) perceived helpfulness and (2) intentions to use e-mental health treatment services as indicators for public acceptability in the respective general population of reviewed studies. This mapping should reduce heterogeneity and help derive implications for systematic reviews and public health strategies. Methods We systematically searched electronic databases (MEDLINE/PubMed, PsycINFO, Psyndex, PsycARTICLES, and Cochrane Library, using reference management software for parallel searches) to identify surveys published in English in peer-reviewed journals between January 2010 and December 2015, focusing on public perceptions about e-mental health treatments outside the context of clinical, psychosocial, or diagnostic interventions. Both indicators were obtained from previous review. Exclusion criteria further involved studies targeting specific groups or programs. Results The simultaneous database search identified 76 nonduplicate records. Four articles from Europe and Australia were included in this scoping review. Sample sizes ranged from 217 to 2411 participants of ages 14-95 years. All included studies used cross-sectional designs and self-developed measures for outcomes related to both defined indicators of public acceptability. Three surveys used observational study designs, whereas one study was conducted as an experiment investigating the impact of brief educational information on attitudes. Taken together, the findings of included surveys suggested that e-mental health treatment services were perceived as less helpful than traditional face-to-face interventions. Additionally, intentions to future use e-mental health treatments were overall smaller in comparison to face-to-face services. Professional support was essential for help-seeking intentions in case of psychological distress. Therapist-assisted e-mental health services were preferred over unguided programs. Unexpectedly, assumed associations between familiarity with Web-based self-help for health purposes or “e-awareness” and intentions to use e-mental health services were weak or inconsistent. Conclusions Considering the marginal amount and heterogeneity of pilot studies focusing on public acceptability of e-mental health treatments, further research using theory-led approaches and validated measures is required to understand psychological facilitator and barriers for the implementation of innovative services into health care.

Objective: Improve documentation quality of end-of-life family meetings in a tertiary intensive care unit (ICU). Design: Before-and-after interventional quality improvement project between October 2018 and February 2020 utilising an electronic pro-forma record. Setting: Australian, University affiliated, mixed medical-surgical 22 bed adult ICU. Participants: Patients who were admitted to the ICU for active management and subsequently died during that ICU admission. We enrolled 50 patients who died before and 50 patients after the introduction of the electronic family meeting pro-forma record. Intervention: Through collaboration with ICU medical and nursing staff, End-of-life Special Interest Group and Clinical Documentation Committee we developed the ICU Family Meeting Discussion Note as an electronic pro-forma record with multiple key fields of entry. Main outcome measures: Patient records were examined for the presence of documented details around patient’s admission, family meetings and specific elements surrounding the patient’s death. Results: The introduction of a pro-forma record markedly improved the quality of documentation of end-of-life care related family meetings. Documentation increased in recording hospital admission date/time (6% vs 84%), meeting location (14% vs 70%), the reason patients were absent from the meeting (34% vs 72%), the Medical Treatment Decision Maker (MTDM) (10% vs 44%), the patient’s resuscitation status (22% vs 54%), and treatment options discussed (78% vs 94%) ( p ⩽ 0.005 for all). Conclusion: Introducing an electronic pro-forma record to facilitate family meeting documentation increased the frequency of important recorded information. Further studies are required to assess whether documentation quality improvements are sustainable and whether they affect patient- or relative-centred outcomes.

Objectives The aims of the study were to investigate discrepancies between general practitioners’ paper medication orders and pharmacy-prepared electronic medication administration charts, back-up paper charts and dose-administration aids, as well as delays between prescribing, charting and administration, at a 90-bed residential aged care facility that used a hybrid paper–electronic medication management system. Methods A cross-sectional audit of medication orders, medication charts and dose-administration aids was performed to identify discrepancies. In addition, a retrospective audit was performed of delays between prescribing and availability of an updated electronic medication administration chart. Medication administration records were reviewed retrospectively to determine whether discrepancies and delays led to medication administration errors. Results Medication records for 88 residents (mean age 86 years) were audited. Residents were prescribed a median of eight regular medicines (interquartile range 5–12). One hundred and twenty-five discrepancies were identified. Forty-seven discrepancies, affecting 21 (24%) residents, led to a medication administration error. The most common discrepancies were medicine omission (44.0%) and extra medicine (19.2%). Delays from when medicines were prescribed to when they appeared on the electronic medication administration chart ranged from 18 min to 98 h. On nine occasions (for 10% of residents) the delay contributed to missed doses, usually antibiotics. Conclusion Medication discrepancies and delays were common. Improved systems for managing medication orders and charts are needed. What is known about the topic? Hybrid paper–electronic medication management systems, in which prescribers’ orders are transcribed into an electronic system by pharmacy technicians and pharmacists to create medication administration charts, are increasingly replacing paper-based medication management systems in Australian residential aged care facilities. The accuracy and safety of these systems has not been studied. What does this paper add? The present study identified discrepancies between general practitioners’ orders and pharmacy-prepared electronic medication administration charts, back-up paper medication charts and dose-administration aids, as well as delays between ordering, charting and administering medicines. Discrepancies and delays sometimes led to medication administration errors. What are the implications for practitioners? Facilities that use hybrid systems need to implement robust systems for communicating medication changes to their pharmacy and reconciling prescribers’ orders against pharmacy-generated medication charts and dose-administration aids. Fully integrated, paperless medication management systems, in which prescribers’ electronic medication orders directly populate an electronic medication administration chart and are automatically communicated to the facility’s pharmacy, could improve patient safety.

Medication errors at transition of care remain a concerning issue. In recent times, the use of integrated electronic medication management systems (EMMS) has caused a reduction in medication errors, but its effectiveness in reducing medication deviations at transition of care has not been studied in hospital-wide settings in Australia. The aim of this study is to assess medication deviations, such as omissions and mismatches, pre-EMMS and post-EMMS implementation at transition of care across a hospital. In this study, patient records were reviewed retrospectively to identify medication deviations (medication omissions and medication mismatches) at admission and discharge from hospital. A total of 400 patient records were reviewed (200 patients in the pre-EMMS and 200 patients in the post-EMMS group). Out of 400 patients, 112 in the pre-EMMS group and 134 patients in post-EMMS group met the inclusion criteria and were included in the analysis. A total of 105 out of 246 patients (42.7%) had any medication deviations on their medications. In the pre-EMMS group, 59 out of 112 (52.7%) patients had any deviations on their medications compared to 46 out of 134 patients (34.3%) from the post-EMMS group (p = 0.004). The proportion of patients with medication omitted from inpatient orders was 36.6% in the pre-EMMS cohort vs. 22.4% in the post-EMMS cohort (p = 0.014). Additionally, the proportion of patients with mismatches in medications on the inpatient charts compared to their medication history was 4.5% in the pre-EMMS group compared to 0% in the post-EMMS group (p = 0.019). Similarly, the proportion of patients with medications omitted from their discharge summary was 23.2% in the pre-EMMS group vs. 12.7% in the post-EMMS group (p = 0.03). Our study demonstrates a reduction in medication deviations after the implementation of the EMMS in hospital settings.

Background: Personally controlled electronic health records (PCEHRs) are being implemented throughout Australia; yet few studies have investigated patients’ experiences of using a PCEHR. Aim: To explore patients’ experiences and perspectives of using a locally developed PCEHR implemented in an Australian health service. Method: Twelve patients completed individual semi-structured telephone interviews, which underwent inductive analysis. Results: Participants described two main interdependent advantages of PCEHRs: improved quality of healthcare through better information sharing and enhanced patient capacity for self-management. To realise these advantages, widespread acceptance and use of PCEHRs by healthcare providers is required, and PCEHRs need to be simple to use and accessible. Conclusion: PCEHRs can produce tangible benefits for patients. However, maximum benefits will be realised when PCEHRs contain a complete collection of relevant health information and are carefully designed for easy use.

This study reviews the literature in relation to virtual strategic alignment models and strategies. From this the researcher develops a framework to test two new strategic alignment instruments designed to measure the espoused preparedness of organisations to operate virtually and the readiness of an organisation to collaborate virtually. These instruments are designed to assist organisations in recognising and exploiting their degree of virtuality and can support organisations in developing new organisational forms that fully leverage the value of their ICT assests. Prior research has attempted to address strategic alignment issues either internally, externally or holistically. A new approach was necessary.

The literature about information systems adoption generally, and specifically the use of EOI within supply chains. indicates that there are significant savings to be made, primarily by reductions in inventory costs. The Iiterature surrounding the Efficient Consumer Response (ECR) movement within the retail supply chain also claims that there are significant savings to be made and that these savings will be shared by partners within the supply chain and be passed on to consumers. This is a two stage study of a local case organisation operating within a duopoly industry environment. The research was conductad during the period of 1999 to 2005.

This research investigated the potential benefits, risks and challenges, innovation properties and viability of cloud computing for records management on an Australian organisation within the mining software development sector. This research involved the use of a case study results analysis as well as a literature analysis. The literature analysis identified the ten potential benefits of cloud computing, as well as the ten risks and challenges associated with cloud computing. It further identified aspects, which needed to be addressed when adopting cloud computing in order to promote innovation within an organisation. The case study analysis was compared against a literature review of ten potential benefits of cloud computing, as well as the ten risks and challenges associated with cloud computing. This was done in order to determine cloud computing’s viability for records management for Company X (The company in the case study). Cloud computing was found to be viable for Company X. However, there were certain aspects, which need to be discussed and clarified with the cloud service provider beforehand in order to mitigate possible risks and compliance issues. It is also recommended that a cloud service provider who complies with international standards, such as ISO 15489, be selected. The viability of cloud computing for organisations similar to Company X (mining software development) followed a related path. These organisations need to ensure that the service provider is compliant with laws in their local jurisdiction, such as Electronic Transactions Act 1999 (Australia, 2011:14-15), as well as laws where their data (in the cloud) may be hosted. The benefits, risks and challenges of records management and cloud computing are applicable to these similar organisations. However, mitigation of these risks needs to be discussed with a cloud service provider beforehand. From an innovation perspective, cloud computing is able to promote innovation within an organisation, if certain antecedents are dealt with. Furthermore, if cloud computing is successfully adopted then it should promote innovation within organisations.
Information Science
M. Inf.

The purpose of this study was to investigate the implementation of Enterprise Content Management (ECM) system at Western Cape Government (WCG), South Africa. The study evaluated the state of the implementation in order to establish whether the system met information and records management requirements and objectives. A probability sampling was used on a total population of 51 respondents and participants. The data were triangulated using multi-methods, whereby both qualitative and quantitative approaches were adopted in a sequential manner. A structured online survey questionnaire, online interviews, and document analysis were used to collect data, which were descriptively analysed. The study revealed that although the WCG has embarked on digitisation projects, which culminated in the department-wide implementation of ECM, the system was not evaluated regularly and consistently. This resulted in an inability to capture the lessons learnt – as well as a failure to realise the full benefits of implementing the system. The findings also showed that ECM implementation at WCG encountered some challenges – for example, inadequate training provided to staff, lack of adequate technology infrastructure, and poor technical support with regard to systems for managing digital records – that impacted on the system’s efficiency. Some of the recommendations of the study are that WCG should consider conducting regular ECM reviews to determine whether the system performs as required in terms of bringing about expected benefits, such as easy retrieval of digitally stored content. Departments should also ensure that there is an alignment among various digital applications for the purpose of creating a single enterprise platform that promotes collaboration and knowledge sharing. A study of ECM implementation in other provinces would enable a comparison of how the system performs elsewhere, including how it could be used as a viable option for organisations to promote digitisation.
Information Science
M. Inf. (Information Science)

Many scholars lament of poor infrastructure to manage and preserve digital records within the public sector in South Africa to support electronic government (egovernment). For example, in South Africa, the national archives’ repository and its subsidiary provincial archives do not have infrastructure to ingest digital records into archival custody. As a result, digital records are left to the creating agencies to manage and preserve. The problem is compounded by the fact that very few public sector organisations in South Africa have procured systems to manage digital records. Therefore, a question is how are digital records managed and stored in these organisations to support e-government? Do public organisations entrust their records to the cloud as an alternative storage given the fact that both physical and virtual storages are a problem? If they do, how do they ensure accessibility, governance, security and long-term preservation of records in the cloud? Utilising the Digital Curation Centre (DCC) Lifecycle Model as a guiding framework, this qualitative study sought to explore digital curation of records in the cloud to support e-government services in South Africa with the view to propose a framework that would guide the public sector to migrate records to the cloud storage. Semi-structured interviews were employed to collect data from the purposively selected Chief Information Officers in the national government departments that have implemented some of the electronic services such as the Department of Arts and Culture, Department of Home Affairs, Department of Higher Education and Training and the Department of Basic Education. Furthermore, the National Archives and Records Services of South Africa was also chosen as it is charged with the statutory regulatory role of records management in governmental bodies. So is the State Information Technology Agency (SITA), a public sector ICT company established in 1999 to consolidate and coordinate the state’s information technology resources in order to achieve cost savings through scale, increase delivery capabilities and enhance interoperability. Interview data were augmented through document analysis of legislation and policies pertaining to data storage. Data were analysed thematically and interpreted in accordance with the objectives of the study. The key finding suggests that although public servants informally and unconsciously put some records in the clouds, government departments in South Africa are sceptical to entrust their records to the cloud due to a number of reasons, such as lack of policy and legislative framework, lack of trust to the cloud storage, jurisdiction, legal implications, privacy, ownership and security risks. This study recommends that given the evolution of technology, the government should regulate cloud storage through policy and legislative promulgation, as well as developing a government-owned cloud managed through SITA in order for all government departments to use it. This study suggests a framework to migrate paperbased records to cloud storage that is controlled by the government.
Information Science
D.Lit. et Phil. (Information Science)

In the last decade, the deployment of Electronic Health Records has increased tremendously in many developed countries. This increasing trend intensifies the need for developing countries like South Africa to implement electronic health record systems in state owned hospitals to facilitate e-referral processes to improve health care delivery. The aim of this research was to investigate the current process of patient record keeping, management, and the referral process of patients within the same hospital and to other hospitals and based on the findings compile an Electronic Health Record (EHR) framework to facilitate e- referral processes. This research study was based on a qualitative case study approach. A multiple data collection technique was used which included group interviews, questionnaires, document analysis and informal discussions with the hospital workers. Data were analysed by categorization and thematic approach. The findings obtained from state hospitals indicated that there is no EHR system which accommodates patient health record systems to facilitate e-referral processes. These findings led to a compilation of the Limpopo Electronic Health Record System (LEHRS) to aid e-referral processes in state hospitals. The increasing need for accurate, reliable, available and accessible EHR will be addressed by the implementation of LEHRS as information will be stored in a central database in a useable format and will be easily accessed.
Computing
M. Tech. (Information Technology)

Background Lung cancer is the number one cause of cancer death worldwide.(1) It is the fifth most commonly diagnosed cancer in Australia (12,741 cases diagnosed in 2018) and the leading cause of cancer death.(2) The number of years of potential life lost to lung cancer in Australia is estimated to be 58,450, similar to that of colorectal and breast cancer combined.(3) While tobacco control strategies are most effective for disease prevention in the general population, early detection via low dose computed tomography (LDCT) screening in high-risk populations is a viable option for detecting asymptomatic disease in current (13%) and former (24%) Australian smokers.(4) The purpose of this Evidence Check review is to identify and analyse existing and emerging evidence for LDCT lung cancer screening in high-risk individuals to guide future program and policy planning. Evidence Check questions This review aimed to address the following questions: 1. What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? 2. What is the evidence of potential harms from lung cancer screening for higher-risk individuals? 3. What are the main components of recent major lung cancer screening programs or trials? 4. What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Summary of methods The authors searched the peer-reviewed literature across three databases (MEDLINE, PsycINFO and Embase) for existing systematic reviews and original studies published between 1 January 2009 and 8 August 2019. Fifteen systematic reviews (of which 8 were contemporary) and 64 original publications met the inclusion criteria set across the four questions. Key findings Question 1: What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? There is sufficient evidence from systematic reviews and meta-analyses of combined (pooled) data from screening trials (of high-risk individuals) to indicate that LDCT examination is clinically effective in reducing lung cancer mortality. In 2011, the landmark National Lung Cancer Screening Trial (NLST, a large-scale randomised controlled trial [RCT] conducted in the US) reported a 20% (95% CI 6.8% – 26.7%; P=0.004) relative reduction in mortality among long-term heavy smokers over three rounds of annual screening. High-risk eligibility criteria was defined as people aged 55–74 years with a smoking history of ≥30 pack-years (years in which a smoker has consumed 20-plus cigarettes each day) and, for former smokers, ≥30 pack-years and have quit within the past 15 years.(5) All-cause mortality was reduced by 6.7% (95% CI, 1.2% – 13.6%; P=0.02). Initial data from the second landmark RCT, the NEderlands-Leuvens Longkanker Screenings ONderzoek (known as the NELSON trial), have found an even greater reduction of 26% (95% CI, 9% – 41%) in lung cancer mortality, with full trial results yet to be published.(6, 7) Pooled analyses, including several smaller-scale European LDCT screening trials insufficiently powered in their own right, collectively demonstrate a statistically significant reduction in lung cancer mortality (RR 0.82, 95% CI 0.73–0.91).(8) Despite the reduction in all-cause mortality found in the NLST, pooled analyses of seven trials found no statistically significant difference in all-cause mortality (RR 0.95, 95% CI 0.90–1.00).(8) However, cancer-specific mortality is currently the most relevant outcome in cancer screening trials. These seven trials demonstrated a significantly greater proportion of early stage cancers in LDCT groups compared with controls (RR 2.08, 95% CI 1.43–3.03). Thus, when considering results across mortality outcomes and early stage cancers diagnosed, LDCT screening is considered to be clinically effective. Question 2: What is the evidence of potential harms from lung cancer screening for higher-risk individuals? The harms of LDCT lung cancer screening include false positive tests and the consequences of unnecessary invasive follow-up procedures for conditions that are eventually diagnosed as benign. While LDCT screening leads to an increased frequency of invasive procedures, it does not result in greater mortality soon after an invasive procedure (in trial settings when compared with the control arm).(8) Overdiagnosis, exposure to radiation, psychological distress and an impact on quality of life are other known harms. Systematic review evidence indicates the benefits of LDCT screening are likely to outweigh the harms. The potential harms are likely to be reduced as refinements are made to LDCT screening protocols through: i) the application of risk predication models (e.g. the PLCOm2012), which enable a more accurate selection of the high-risk population through the use of specific criteria (beyond age and smoking history); ii) the use of nodule management algorithms (e.g. Lung-RADS, PanCan), which assist in the diagnostic evaluation of screen-detected nodules and cancers (e.g. more precise volumetric assessment of nodules); and, iii) more judicious selection of patients for invasive procedures. Recent evidence suggests a positive LDCT result may transiently increase psychological distress but does not have long-term adverse effects on psychological distress or health-related quality of life (HRQoL). With regards to smoking cessation, there is no evidence to suggest screening participation invokes a false sense of assurance in smokers, nor a reduction in motivation to quit. The NELSON and Danish trials found no difference in smoking cessation rates between LDCT screening and control groups. Higher net cessation rates, compared with general population, suggest those who participate in screening trials may already be motivated to quit. Question 3: What are the main components of recent major lung cancer screening programs or trials? There are no systematic reviews that capture the main components of recent major lung cancer screening trials and programs. We extracted evidence from original studies and clinical guidance documents and organised this into key groups to form a concise set of components for potential implementation of a national lung cancer screening program in Australia: 1. Identifying the high-risk population: recruitment, eligibility, selection and referral 2. Educating the public, people at high risk and healthcare providers; this includes creating awareness of lung cancer, the benefits and harms of LDCT screening, and shared decision-making 3. Components necessary for health services to deliver a screening program: a. Planning phase: e.g. human resources to coordinate the program, electronic data systems that integrate medical records information and link to an established national registry b. Implementation phase: e.g. human and technological resources required to conduct LDCT examinations, interpretation of reports and communication of results to participants c. Monitoring and evaluation phase: e.g. monitoring outcomes across patients, radiological reporting, compliance with established standards and a quality assurance program 4. Data reporting and research, e.g. audit and feedback to multidisciplinary teams, reporting outcomes to enhance international research into LDCT screening 5. Incorporation of smoking cessation interventions, e.g. specific programs designed for LDCT screening or referral to existing community or hospital-based services that deliver cessation interventions. Most original studies are single-institution evaluations that contain descriptive data about the processes required to establish and implement a high-risk population-based screening program. Across all studies there is a consistent message as to the challenges and complexities of establishing LDCT screening programs to attract people at high risk who will receive the greatest benefits from participation. With regards to smoking cessation, evidence from one systematic review indicates the optimal strategy for incorporating smoking cessation interventions into a LDCT screening program is unclear. There is widespread agreement that LDCT screening attendance presents a ‘teachable moment’ for cessation advice, especially among those people who receive a positive scan result. Smoking cessation is an area of significant research investment; for instance, eight US-based clinical trials are now underway that aim to address how best to design and deliver cessation programs within large-scale LDCT screening programs.(9) Question 4: What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Assessing the value or cost-effectiveness of LDCT screening involves a complex interplay of factors including data on effectiveness and costs, and institutional context. A key input is data about the effectiveness of potential and current screening programs with respect to case detection, and the likely outcomes of treating those cases sooner (in the presence of LDCT screening) as opposed to later (in the absence of LDCT screening). Evidence about the cost-effectiveness of LDCT screening programs has been summarised in two systematic reviews. We identified a further 13 studies—five modelling studies, one discrete choice experiment and seven articles—that used a variety of methods to assess cost-effectiveness. Three modelling studies indicated LDCT screening was cost-effective in the settings of the US and Europe. Two studies—one from Australia and one from New Zealand—reported LDCT screening would not be cost-effective using NLST-like protocols. We anticipate that, following the full publication of the NELSON trial, cost-effectiveness studies will likely be updated with new data that reduce uncertainty about factors that influence modelling outcomes, including the findings of indeterminate nodules. Gaps in the evidence There is a large and accessible body of evidence as to the effectiveness (Q1) and harms (Q2) of LDCT screening for lung cancer. Nevertheless, there are significant gaps in the evidence about the program components that are required to implement an effective LDCT screening program (Q3). Questions about LDCT screening acceptability and feasibility were not explicitly included in the scope. However, as the evidence is based primarily on US programs and UK pilot studies, the relevance to the local setting requires careful consideration. The Queensland Lung Cancer Screening Study provides feasibility data about clinical aspects of LDCT screening but little about program design. The International Lung Screening Trial is still in the recruitment phase and findings are not yet available for inclusion in this Evidence Check. The Australian Population Based Screening Framework was developed to “inform decision-makers on the key issues to be considered when assessing potential screening programs in Australia”.(10) As the Framework is specific to population-based, rather than high-risk, screening programs, there is a lack of clarity about transferability of criteria. However, the Framework criteria do stipulate that a screening program must be acceptable to “important subgroups such as target participants who are from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, people from disadvantaged groups and people with a disability”.(10) An extensive search of the literature highlighted that there is very little information about the acceptability of LDCT screening to these population groups in Australia. Yet they are part of the high-risk population.(10) There are also considerable gaps in the evidence about the cost-effectiveness of LDCT screening in different settings, including Australia. The evidence base in this area is rapidly evolving and is likely to include new data from the NELSON trial and incorporate data about the costs of targeted- and immuno-therapies as these treatments become more widely available in Australia.