NURS 700 Week 2 Written Assignment 1: Locating the Evidence Example

Locating the Evidence for Raising Lung Cancer Screening Completion in Rural Primary Care: A Clinical Question, a Reproducible Search and a First Map of the Evidence

The Practice Problem

Blue Ridge Family Health is a network of four rural primary care clinics in the Appalachian region of southwest Virginia, serving about 21,000 patients, many of whom have smoked for decades. More people in the region die of lung cancer than of any other cancer. Yearly low-dose computed tomography for people between 50 and 80 whose tobacco history reaches 20 pack-years, and who either smoke now or gave up cigarettes less than 15 years ago, lowers lung cancer deaths, yet a registry review last spring found that only 8% of the network's eligible patients had completed a screening scan in the previous year, and fewer than half of those returned for their annual follow-up scan. Clinicians report that the pack-year history is often missing from the record, that visits are crowded with other priorities and that the nearest scanner is 40 minutes away for many patients.

The network's experience reflects a national problem. Using 2024 National Health Interview Survey data representing about 37.5 million US adults with a smoking history, Jia et al. (2026) found that only 17.8% of adults eligible under the federal criteria reported screening in the past twelve months. An analysis of 2024 state data found that screening prevalence varied widely across states but was not significantly correlated with the number or density of screening facilities (Cho et al., 2026), which suggests that access to scanners alone does not explain low uptake. For a DNP project, the problem is therefore not building more capacity but helping eligible patients reach the capacity that exists.

Why the Rural Context Matters

The rural setting shapes both the problem and the evidence needed to solve it. Patients at Blue Ridge are older and more likely to smoke than the state average, many are paid by the hour and lose wages for any appointment, and some must arrange rides to reach the hospital that operates the nearest scanner. Clinicians have limited time and often see patients for several chronic conditions in a single visit. A strategy that works in an urban integrated system, where scans can be scheduled in the same building and patients receive portal messages, may fail where the barriers are distance, cost of travel and missed work. For that reason, the search was designed to capture studies of patient barriers and implementation as well as trials, and the inclusion criteria kept qualitative studies that a narrower search for trials alone would have discarded, so that later assignments can judge how well the trial evidence fits the network's patients.

The Clinical Question

The practice problem was translated into a PICOT question: In adults aged 50 to 80 who are eligible for lung cancer screening and receive care in rural primary care clinics (P), does nurse-led outreach with decision counseling and stepped reminders (I), compared with usual care (C), increase completion of low-dose CT screening (O) within six months (T)? Each element of the question maps onto a block of search terms, which made the search reproducible.

The Search Strategy

The search was conducted in September in four databases: CINAHL Complete, PubMed, Scopus and the Cochrane Library. The search string combined three blocks with the Boolean operator AND: the population and topic block ("lung cancer screening" OR "low-dose CT" OR "LDCT"), the intervention block (navigat OR outreach OR reminder OR "decision aid" OR "shared decision" OR "decision counseling") and the outcome block (uptake OR completion OR adherence OR participation). Limits were English language, publication from 2021 to the present and studies conducted in adults. Subject headings, such as the MeSH term Early Detection of Cancer, were added in PubMed to capture indexed studies that used other wording.

The search returned 412 records. After 131 duplicates were removed, 281 titles and abstracts were screened, and 238 were excluded because they addressed screening technology, imaging findings, smoking cessation alone or settings outside primary care. Forty-three full texts were reviewed, and 14 studies met the inclusion criteria: original research or systematic reviews that tested or examined patient- or system-level strategies for screening uptake or adherence, or that described uptake among eligible adults.

A First Map of the Evidence

The strongest single source is a systematic review of shared decision-making for lung cancer screening, which included 31 US studies and concluded with low certainty that shared decision-making, including when delivered by care coordinators or navigators, may increase participation, and with high certainty that it does not increase decisional conflict or regret (Landsteiner et al., 2026). Three trials address the intervention directly. In a primary care trial, patients randomized to telephone outreach and decision counseling were more likely than usual care patients to receive a screening referral or order, 16% compared with 9% (DiCarlo et al., 2026). A large pragmatic trial at Kaiser Permanente Washington found that stepped reminders, in which a coordinator pended orders for physicians and prompted patients to schedule, raised adherence to annual screening by 27.7 percentage points, while a health communication intervention did not help (Wernli et al., 2026). By contrast, a low-intensity pre-visit letter encouraging patients to raise screening with their physician did not increase orders (Carroll et al., 2026). The early pattern is clear: what works is active outreach by a person or a system, not a message that leaves the next step to the patient.

What Eligible Patients and Clinicians Report

The survey and qualitative studies help explain why passive approaches fail. In a national panel of 521 eligible adults who had never been screened, 56.2% had not heard of lung cancer screening and only 6.5% had discussed it with a clinician in the past year, although a third said they would definitely be screened if a clinician recommended it (Samami et al., 2026). Interviews with primary care providers, community health navigators and radiology staff in rural and urban Florida identified barriers in knowledge of eligibility and insurance coverage, the quality of pack-year data in the record, competing priorities during visits, and patients' difficulty with time off work, transportation and scheduling, while automated record alerts and trust between patients and clinicians eased the process (Reid et al., 2026). These findings match what Blue Ridge clinicians describe and suggest that an intervention must address both the clinic's systems and the patient's practical barriers.

What the First Map Suggests and What It Lacks

Three points emerge from the first map. First, interventions that involve a person, such as a nurse or coordinator who calls, counsels and schedules, appear more effective than passive communication. Second, adherence to annual follow-up is a separate problem from first-time screening and may need its own strategy, since a patient who completes one scan has already overcome the barriers of awareness and access but may still drift away from the yearly schedule. Third, most of the evidence comes from integrated health systems with strong electronic infrastructure, not from small rural networks like Blue Ridge, which will make applicability a central question in later assignments. The map also shows gaps. Few studies were set in rural Appalachia, few reported results by distance to the scanner, and none tested a model in which registered nurses already working in the clinics deliver the outreach. The search itself has limits. Restricting it to English and to the last five years may have excluded older trials of navigation that informed current programs, and searching only four databases may have missed studies in public health or rural health journals not indexed there. A follow-up search of the reference lists of the systematic review and the largest trial will be completed before the annotated bibliography, and a search of gray literature, such as state cancer control plans and reports from rural health associations, will look for local programs that may not have been published in journals.

Searching as Stewardship

Searching carefully is more than a technical skill. Proverbs contrasts the careful planner, whose work ends in plenty, with the hasty person, whose shortcuts end in want (English Standard Version Bible, 2001/2016, Proverbs 21:5). A hasty search that stops at the first supportive article can lead a practice to invest in an intervention that does not work, as the negative nudge trial illustrates. A diligent search protects patients and the organization's resources by showing what the evidence actually supports.

Conclusion

This first assignment turned a local problem, low lung cancer screening completion in a rural primary care network, into a PICOT question and a reproducible search that retained 14 studies. The early evidence favors active, person-led outreach with decision counseling and reminders over passive messaging, while leaving open how well these findings transfer to rural clinics. The next assignment will critique the strongest trial in depth.

References

Carroll, N. M., Maclennan, A. J., Wain, K. F., Hixon, B., Steiner, J., & Ritzwoller, D. P. (2026). Increasing uptake of lung cancer screening through a patient "nudge": A randomized pragmatic trial. American Journal of Preventive Medicine. Advance online publication. https://doi.org/10.1016/j.amepre.2026.108552

Cho, B., Stallings-Smith, S., & Kim, H. (2026). State disparities in lung cancer screening uptake despite facility availability in the United States, 2024-2025: A cross-sectional ecological study. Cancer Control, 33. https://doi.org/10.1177/10732748261494041

DiCarlo, M., Shimada, A., Sifri, R., Johnson, M., Keith, S. W., Zhan, T., Jackson, H., Indictor, A., Burgess, N., Mahon, I., Pisano, E., & Myers, R. E. (2026). Increasing lung cancer screening referral/order and completion rates in primary care through patient outreach and shared decision making. Journal of Medical Screening. Advance online publication. https://doi.org/10.1177/09691413261479224

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Jia, Y., Zhao, J., & Rivera, M. P. (2026). Lung cancer screening uptake among adults newly eligible under the 2023 American Cancer Society guideline compared with USPSTF-eligible adults: A nationwide cross-sectional study. Chest. Advance online publication. https://doi.org/10.1016/j.chest.2026.09.005

Landsteiner, A., Zerzan, N., Ullman, K. E., Anthony, M., Claussen, A. M., Bayer, R., Do, T., Gustavson, A. M., Melzer, A. C., & Wilt, T. J. (2026). Shared decision-making for lung cancer screening: A systematic review. CHEST Pulmonary, 4(1), Article 100222. https://doi.org/10.1016/j.chpulm.2025.100222

Reid, M. J., LeLaurin, J. H., Ali, S., Sorial, C., Bylund, C. L., Woodard, J. N., Wollney, E. N., Goede, D. L., Lee, J. H., Nelson, D. S., Carter-Bawa, L., & Salloum, R. G. (2026). Identifying barriers and strategies to support a community navigator-driven approach for lung cancer screening. Current Oncology, 33(9), Article 499. https://doi.org/10.3390/curroncol33090499

Samami, E., Sarkar, S., Zaidi, M., & Poghosyan, H. (2026). Determinants of lung cancer screening intention among eligible individuals. Lung Cancer, 220, Article 109540. https://doi.org/10.1016/j.lungcan.2026.109540

Wernli, K. J., Anderson, M. L., Palazzo, L., Luce, C., Bezman, N., Rogers, K., Chin, M., Gao, H., Ralston, J., Su, Y. R., Carter-Bawa, L., Triplette, M., Tuzzio, L., Vasavada, A., & Green, B. B. (2026). Health communication and stepped reminders interventions for lung cancer screening: A randomized clinical trial. JAMA Internal Medicine. Advance online publication. https://doi.org/10.1001/jamainternmed.2026.3666