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Linda Dowling
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P3.11 - Screening and Early Detection (Not CME Accredited Session) (ID 977)
- Event: WCLC 2018
- Type: Poster Viewing in the Exhibit Hall
- Track:
- Presentations: 3
- Moderators:
- Coordinates: 9/26/2018, 12:00 - 13:30, Exhibit Hall
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P3.11-06 - Improving Lung Cancer Screening Completion Rates in a Primary Care Practice in Large Urban Academic Medical Center (ID 13536)
12:00 - 13:30 | Presenting Author(s): Linda Dowling
- Abstract
Background
Despite implementation of a physician-facing electronic health record (EHR) best practice alert (BPA) with robust medical decision making and documentation, only 7.3% of eligible patients (85 of 1170) throughout the institution completed a low-dose CT (LDCT) for lung cancer screening in 6 months (May 1st to November 1, 2017).
The objective is to improve lung cancer screening by:
1. Describing primary care referral patterns and status among eligible patients
2. Identifying system, patient and provider-level barriers to referral and completion
3. Developing and testing targeted interventions
Success will be measured by reducing number of eligible patients overdue for screening by 50% in the next 6 months.
a9ded1e5ce5d75814730bb4caaf49419 Method
An Epic EHR report identified patients with an overdue lung cancer screening BPA within one practice representing approximately 40% of primary care (16,000 visits in 6 months). Through chart review, we quantified number of patients at different points of the referral pathway.
New interventions were developed for the most common categories of patients overdue for screening: Those with orders that had not scheduled the exam and those with no order and no documentation of why in the EHR.
Lung Cancer Screening Coordinators contacted patients with current orders and began scheduling LDCT exams. (Intervention 1).
Division leadership, medical directors, primary care providers (PCP), and the practice nurse manager were engaged to design an intervention to address patients with no LDCT order (Intervention 2)
4c3880bb027f159e801041b1021e88e8 Result
The total number of LDCTs performed in the first 12 weeks after starting the intervention was almost equal to the performed in the 6 month baseline period. (12 vs 14).
The percentage of patients overdue with orders increased from 28% to 37.5%. Only 7 of the original 18 with orders not scheduled remained in that category at 12 weeks. The percentage of patients overdue with no order and no documentation decreased from 65.9% of to 51.3%.
Fifteen of 41 with no order and no reason documented (36.5%) were newly identified at 12 weeks, i.e. not identified by the baseline query.
The most significant limitation to measuring 12-week outcomes is that patients have not yet completed their scheduled PCP appointments and LDCT appointments.
8eea62084ca7e541d918e823422bd82e Conclusion
Multiple challenges were identified at system, patient and provider levels:
*The BPA lacks specificity.
*This patient subpopulation has a high prevalence of comorbidities and chronic conditions.
*PCPs expressed skepticism regarding evidence for lung cancer screening, perceived lack of benefit for some patients and competing demands.
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P3.11-07 - The Quality of Screening: Comparing the Rush Lung Cancer Screening Program to the NLST and the VA Lung Cancer Screening Demonstration Project (ID 13537)
12:00 - 13:30 | Presenting Author(s): Linda Dowling
- Abstract
Background
The National Lung Screening Trial (NLST) was conducted for the purpose of determining the efficacy of using a low dose computed tomography (LDCT) scan to screen for lung cancer screening versus chest x-ray. Findings demonstrated a reduction in mortality by 20.0%.
In 2013, informed by the findings from the NLST, the United States Preventative Services Task Force (UPSTF) gave lung cancer screening a grade B recommendation. This recommendation eventually led to both private insurance coverage and in 2015, Centers for Medicare and Medicaid Services (CMS) coverage of low dose computed tomography (LDCT) scans to screen for lung cancer.
In 2017, the US Department of Veterans Affairs (VA) published the experience of implementing a lung cancer screening program (LCSDP). This publication attracted the attention of the medical community and media, generating concern over the value of LDCT scans indicated to screen for lung cancer.
The Rush University Medical Center Lung Cancer Screening Program (RLCSP) is in its third year of implementation and adheres to best practices for the evolving discipline of lung cancer screening.
a9ded1e5ce5d75814730bb4caaf49419 Method
To compare the structure and findings of the Rush Lung Cancer Screening Program (RLCSP) to two well-known published initiatives: the National Lung Screening Trial (NLST) and Implementation of Lung Cancer Screening in the Veterans Health Administration (LCSDP).
4c3880bb027f159e801041b1021e88e8 Result
1 in 29 people screened with the RLCSP has lung cancer, compared with 1 in 68 people screened with the LCSDP, and 1 in 320 screened with the NLST. The RLCSP has a more diverse demographic base, and fewer false positive scans than the NLST or LCSDP.
8eea62084ca7e541d918e823422bd82e Conclusion
The NLST is a research study that was conducted for the purpose of testing the efficacy of using a LDCT scan versus chest x-ray to screen for lung cancer.
The purpose of the LCSDP is to address feasibility of implementing a lung cancer screening program within the VA system; The LCSDP is an implementation project and not a clinical research study.
RLCSP is a screening program that was implemented in a university hospital setting, which closely adheres to best practices with strong results. Data from the RLCSP supports findings from the NLST that LDCT is an effective scan to screen for lung cancer.
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P3.11-08 - Lung Cancer Screening at an Academic Medical Center: Early Patterns of Practice (ID 13964)
12:00 - 13:30 | Presenting Author(s): Linda Dowling
- Abstract
Background
Lung cancer screening with low dose computed tomography (LDCT) is associated with a reduction in lung cancer mortality. The Center for Medicare and Medicaid Services (CMS) offers coverage for LDCT, indicated for lung cancer screening, if patients are between ages 55 and 77, are a current smoker or former smoker who has quit smoking in the past 15 years, have a greater than 30 pack year smoking history, and shows no signs or symptoms of lung cancer (hemoptysis and/or weightless).
Rush University Medical Center has a Best Practice Alert (BPA) in Epic to notify physicians of patients who meet criteria to receive LDCT scans for lung cancer screening. The BPA fires based on patient’s age and documented pack year smoking history. Successful utilization of the BPA relies heavily on accurate smoking documentation. As part of an ongoing project characterizing the population who ultimately undergoes screening, it became evident that a significant number of patients whom may be eligible for screening are missed due to incomplete smoking documentation. These initial findings highlight the need to develop an improved, accurate, and more convenient system to document smoking history.
a9ded1e5ce5d75814730bb4caaf49419 Method
A retrospective chart review was performed, utilizing electronic medical records, for data from October 2015-October 2017. Data was collected on age, gender, and smoking status. Based on this timeframe, data for 50,421 patients from Rush University Medical Center (RUMC) and Rush Oak Park Hospital (ROPH) was analyzed. Age was restricted to 55-77 years to match CMS re-imbursement criteria.
4c3880bb027f159e801041b1021e88e8 Result
Of the 50,421 patient charts analyzed, 2,720 (5%) met eligibility criteria for lung cancer screening based on their documented smoking history. The majority of patients, 38,197 (76%), had incomplete smoking history documentation. Out of the patients with incomplete smoking history documentation, many charts were missing documentation of smoking history in pack year, and/or the number of years it has been since the patient quit smoking.
8eea62084ca7e541d918e823422bd82e Conclusion
Data identifies a key weakness in electronic health record documentation of smoking history at RUMC and ROPH. Since the BPA for lung cancer screening only triggers with a documented smoking history of greater than 30 pack years, patients who may be eligible for lung cancer screening are not being identified. By advocating for more thorough documentation of patient smoking history, we can optimize use of the BPA and provide patients with better health management.
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