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The American Journal of Managed Care June 2018
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Initial Results of a Lung Cancer Screening Demonstration Project: A Local Program Evaluation
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Initial Results of a Lung Cancer Screening Demonstration Project: A Local Program Evaluation

Angela E. Fabbrini, MPH; Sarah E. Lillie, PhD, MPH; Melissa R. Partin, PhD; Steven S. Fu, MD, MSCE; Barbara A. Clothier, MS, MA; Ann K. Bangerter, BS; David B. Nelson, PhD; Elizabeth A. Doro, BS; Brian J. Bell, MD; and Kathryn L. Rice, MD
Results, lessons, and challenges of a local lung cancer screening program within a national demonstration project.

Objectives: To describe participation rates, results, and lessons learned from a lung cancer screening (LCS) demonstration project.

Study Design: Prospective observational study at 1 of 8 centers participating in a national Veterans Health Administration LCS demonstration project.

Methods: An electronic health record (EHR) algorithm and tobacco pack-year (TPY) information prompt identified patients potentially eligible for LCS. LCS invitation was planned to consist of shared decision-making materials, an invitation letter to call the LCS manager, a reminder letter, and an outreach phone call for nonresponders. The outreach call was subsequently dropped due to time constraints on the LCS manager. Lung nodules and incidental findings on LCS low-dose computed tomography (LDCT) were recorded in templated radiology reports and tracked with EHR notes.

Results: Of 6133 potentially eligible patients, we identified 1388 patients with eligible TPY information: 918 were invited for LCS and 178 (19%) completed LCS. LCS completion was more likely in patients in the mailing-plus-call outreach group (phase I) compared with the mail-only group (phase II) (22% vs 9%; P <.001). Among those completing an LDCT, 61% had lung nodules requiring follow-up: 43% of the nodules were less than 4 mm in diameter, 12 patients required further diagnostic evaluation, and 2 had lung malignancies. There were 179 incidental LDCT findings in 116 patients, and 20% were clinically significant.

Conclusions: Important considerations in LCS are accurate identification of eligible patients, balancing invitation approaches with resource constraints, and establishing standardized methods for tracking numerous small lung nodules and incidental findings detected by LDCT.

Am J Manag Care. 2018;24(6):272-277
Takeaway Points
  • Lung cancer screening (LCS) is a complex process that is best supported by a managed system approach in order to accurately identify eligible patients, provide consistent shared decision making (SDM), ensure standardized low-dose computed tomography interpretation, and track results over time.
  • Optimal approaches to patient invitation for LCS and SDM are unclear.
  • A better understanding of the clinical significance of small (<4 mm diameter) lung nodules and incidental findings is needed.
Lung cancer is the leading cause of cancer morbidity and mortality in the United States.1 Given the high disease burden and aggressive nature of lung cancer, considerable effort has been directed at early detection and treatment through lung cancer screening (LCS) trials. The National Lung Screening Trial (NLST) reported a 20% relative reduction in lung cancer mortality with low-dose computed tomography (LDCT) compared with chest x-rays.2 The primary principle of LCS is detection and surveillance of small lung nodules over time for changes that are suspicious for malignancy.

The NLST served as the primary basis for the recent United States Preventive Services Task Force recommendation for annual LCS with LDCT for high-risk individuals.3 Several professional societies have also endorsed annual LDCT for high-risk individuals,4-8 and in 2015, CMS added LCS as a reimbursable preventive service.9 Despite the benefits of LDCT for LCS on both lung cancer and all-cause mortality, there are concerns about high costs and potential associated harms, including false-positive results,2 overdiagnosis,10,11 radiation exposure,12 and psychological distress, particularly for patients who receive an indeterminate result.13,14

To gain information about the feasibility of implementing these recommendations, the Veterans Health Administration (VHA) completed a National Demonstration Project. The Minneapolis Veterans Affairs Health Care System (MVAHCS) was 1 of 8 demonstration sites. We report the initial results of LCS at the MVAHCS to provide more detailed information than was collected in the National VHA Demonstration Project regarding tobacco pack-year (TPY) information, patient uptake rates of LCS in response to different invitation approaches, characteristics of lung nodules detected on LDCT, and the clinical significance of incidental findings on LDCTs that are unrelated to LCS.


Setting and Patient Eligibility

Initial LCS results at the MVAHCS between January 1, 2014, and May 22, 2015, were analyzed. We employed a national VHA electronic health record (EHR) algorithmic program to identify potential eligible patients who met the preliminary LCS criteria at the time of an appointment with their primary care provider (PCP). The criteria were: being aged 55 to 80 years; having no diagnosis codes in the EHR for hospice care or lung, esophageal, pancreatic, or liver cancer; having no chest CT in the previous year; and not being previously coded in the EHR as not expected to live more than 6 months. If a patient met all of these criteria, the algorithm activated an EHR prompt for the appointment check-in nurse to collect TPY information (ie, current cigarette smoking status, years smoked, and average lifetime packs per day).

To provide equitable access and prevent exceeding the initial screening capacity for LCS, the National VHA Demonstration Project recommended gradual local implementation by a random rolling activation of EHR prompts per individual PCPs. At our site, providers opted out of this approach because of an existing program of a manager-driven lung nodule tracking system. We therefore elected to randomly choose patients with eligible TPY information (≥30 pack-years and either currently smoking or quit <15 years ago) for invitation to LCS using a 2:1 ratio (2 patients selected for LCS invitation for every 1 usual care patient), by the LCS program manager, an MPH with training in health education and extensive clinical experience. The MVAHCS Internal Review Board determined that patient-level randomization for invitation to the Demonstration Project was not considered research, but rather a quality improvement and feasibility evaluation method. Randomization was implemented in blocks, with groups assigned using random number generator–based software algorithms.

All MVAHCS patients had access to a comprehensive Tobacco Cessation Program, which includes assessment of smoking status via an annual EHR prompt, patient education materials, individual and group behavioral therapy, and pharmacotherapy.

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