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Slatore CG, Hooker ER, Shull S, Golden SE, Melzer AC. Association of patient and health care organization factors with incidental nodule guidelines adherence: A multi-system observational study. Lung Cancer 2024; 190:107526. [PMID: 38452601 PMCID: PMC10999337 DOI: 10.1016/j.lungcan.2024.107526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/01/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Health care organizations are increasingly developing systems to ensure patients with pulmonary nodules receive guideline-adherent care. Our goal was to determine patient and organization factors that are associated with radiologist adherence as well as clinician and patient concordance to 2005 Fleischner Society guidelines for incidental pulmonary nodule follow-up. MATERIALS Trained researchers abstracted data from the electronic health record from two Veterans Affairs health care systems for patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. METHODS We classified radiology reports and patient follow-up into two categories. Radiologist-Fleischner Adherence was the agreement between the radiologist's recommendation in the computed tomography report and the 2005 Fleischner Society guidelines. Clinician/Patient-Fleischner Concordance was agreement between patient follow-up and the guidelines. We calculated multivariable-adjusted predicted probabilities for factors associated with Radiologist-Fleischner Adherence and Clinician/Patient-Fleischner Concordance. RESULTS Among 3150 patients, 69% of radiologist recommendations were adherent to 2005 Fleischner guidelines, 4% were more aggressive, and 27% recommended less aggressive follow-up. Overall, only 48% of patients underwent follow-up concordant with 2005 Fleischner Society guidelines, 37% had less aggressive follow-up, and 15% had more aggressive follow-up. Radiologist-Fleischner Adherence was associated with Clinician/Patient-Fleischner Concordance with evidence for effect modification by health care system. CONCLUSION Clinicians and patients seem to follow radiologists' recommendations but often do not obtain concordant follow-up, likely due to downstream differential processes in each health care system. Health care organizations need to develop comprehensive and rigorous tools to ensure high levels of appropriate follow-up for patients with pulmonary nodules.
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Affiliation(s)
- Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Division of Pulmonary & Critical Care Medicine, Department of Medicine, and Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Elizabeth R Hooker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Sarah Shull
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Sara E Golden
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Anne C Melzer
- Section of Pulmonary & Critical Care Medicine, VA Minneapolis Health Care System, 1 Veterans Dr, Minneapolis, MN 55417, USA
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2
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Lee G, Hill LP, Schroeder MC, Kraus SJ, El-Abiad KMB, Hoffman RM. Adherence to Annual Lung Cancer Screening in a Centralized Academic Program. Clin Lung Cancer 2024; 25:e18-e25. [PMID: 37925362 DOI: 10.1016/j.cllc.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/23/2023] [Accepted: 10/09/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Adherence to lung cancer screening (LCS) protocols is critical for achieving mortality reductions. However, adherence rates, particularly for recommended annual screening among patients with low-risk findings, are often sub-optimal. We evaluated annual LCS adherence for patients with low-risk findings participating in a centralized screening program at a tertiary academic center. PATIENTS AND METHODS We conducted a retrospective, observational cohort study of a centralized lung cancer screening program launched in July 2018. We performed electronic medical review of 337 patients who underwent low-dose CT (LDCT) screening before February 1, 2021 (to ensure ≥ 15 months follow up) and had a low-risk Lung-RADS score of 1 or 2. Captured data included patient characteristics (smoking history, Fagerstrom score, environmental exposures, lung cancer risk score), LDCT imaging dates, and Lung-RADS results. The primary outcome measure was adherence to annual screening. We used multivariable logistic regression models to identify factors associated with adherence. RESULTS Overall, 337 patients had an initial Lung-RADS result of 1 (n = 189) or 2 (n = 148). Among this cohort, 139 (73.5%) of Lung-RADS 1 and 111 (75.0%) of Lung-RADS 2 patients completed the annual repeat LDCT within 15 months, respectively. The only patient characteristic associated with adherence was having Medicaid coverage; compared to having private insurance, Medicaid patients were less adherent (adjusted OR = 0.37, 95% CI = 0.15-0.92). No other patient characteristic was associated with adherence. CONCLUSION Our centralized screening program achieved a high initial annual adherence rate. Although LCS has first-dollar insurance coverage, other socioeconomic concerns may present barriers to annual screening for Medicaid recipients.
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Affiliation(s)
- Grace Lee
- University of Iowa Carver College of Medicine, Iowa City, IA.
| | - Laura P Hill
- Internal Medicine Primary Care, Mercy Hospital, St. Louis, MO
| | - Mary C Schroeder
- Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA
| | - Sara J Kraus
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Richard M Hoffman
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa Carver College of Medicine, Iowa City, IA
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3
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Abraham P, Haddad A, Bishay AE, Bishay S, Sonubi C, Jaramillo-Cardoso A, Sava M, Yee J, Flores EJ, Spalluto LB. Social Determinants of Health in Imaging-based Cancer Screening: A Case-based Primer with Strategies for Care Improvement. Radiographics 2023; 43:e230008. [PMID: 37824411 PMCID: PMC10612293 DOI: 10.1148/rg.230008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/05/2023] [Accepted: 05/24/2023] [Indexed: 10/14/2023]
Abstract
Health disparities, preventable differences in the burden of disease and disease outcomes often experienced by socially disadvantaged populations, can be found in nearly all areas of radiology, including emergency radiology, neuroradiology, nuclear medicine, image-guided interventions, and imaging-based cancer screening. Disparities in imaging-based cancer screening are especially noteworthy given the far-reaching population health impact. The social determinants of health (SDoH) play an important role in disparities in cancer screening and outcomes. Through improved understanding of how SDoH can drive differences in health outcomes in radiology, radiologists can effectively provide patient-centered, high-quality, and equitable care. Radiologists and radiology practices can become active partners in efforts to assist patients along their imaging journey and overcome existing barriers to equitable cancer screening care for traditionally marginalized populations. As radiology exists at the intersection of diagnostic imaging, image-guided diagnostic intervention, and image-guided treatment, radiologists are uniquely positioned to design these strategies. Cost-effective and socially conscious strategies that address barriers to equitable care can improve both public health and equitable health outcomes. Potential strategies include championing supportive health policy, reducing out-of-pocket costs, increasing price transparency, improving education and outreach efforts, ensuring that appropriate language translation services are available, providing individualized assistance with appointment scheduling, and offering transportation assistance and childcare. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Peter Abraham
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Aida Haddad
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Anthony E. Bishay
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Steven Bishay
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Chiamaka Sonubi
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Adrian Jaramillo-Cardoso
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Melinda Sava
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Judy Yee
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Efren J. Flores
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
| | - Lucy B. Spalluto
- From the Department of Radiology, University of California San Diego,
200 W Arbor Dr, San Diego, CA 92103 (P.A., A.H.); Vanderbilt University School
of Medicine, Nashville, Tenn (A.E.B., S.B.); Department of Rehabilitation
Medicine, Emory University School of Medicine, Atlanta, Ga (C.S.); Department of
Radiology, Vanderbilt University Medical Center, Nashville, Tenn (A.J.C.,
L.B.S.); Advanced Diagnostic Imaging, Nashville, Tenn (M.S.); Department of
Radiology, Albert Einstein College of Medicine, New York, NY (J.Y.); Department
of Radiology, Massachusetts General Hospital, Boston, Mass (E.J.F.);
Vanderbilt-Ingram Cancer Center, Nashville, Tenn (L.B.S.); and Veterans Health
Administration–Tennessee Valley Health Care System Geriatric Research,
Education and Clinical Center (GRECC), Nashville, Tenn (L.B.S.)
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4
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Blackburn CW, Richardson SM, DeVita RR, Dong O, Faraji N, Wurtz LD, Collier CD, Getty PJ. What Is the Prevalence of Clinically Important Findings Among Incidentally Found Osseous Lesions? Clin Orthop Relat Res 2023; 481:1993-2002. [PMID: 36975798 PMCID: PMC10499109 DOI: 10.1097/corr.0000000000002630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/31/2023] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Patients with incidentally found musculoskeletal lesions are regularly referred to orthopaedic oncology. Most orthopaedic oncologists understand that many incidental findings are nonaggressive and can be managed nonoperatively. However, the prevalence of clinically important lesions (defined as those indicated for biopsy or treatment, and those found to be malignant) remains unknown. Missing clinically important lesions can result in harm to patients, but needless surveillance may exacerbate patient anxiety about their diagnosis and accrue low-value costs to the payor. QUESTIONS/PURPOSES (1) What percentage of patients with incidentally discovered osseous lesions referred to orthopaedic oncology had lesions that were clinically important, defined as those receiving biopsy or treatment or those found to be malignant? (2) Using standardized Medicare reimbursements as a surrogate for payor expense, what is the value of reimbursements accruing to the hospital system for the imaging of incidentally found osseous lesions performed during the initial workup period and during the surveillance period, if indicated? METHODS This was a retrospective study of patients referred to orthopaedic oncology for incidentally found osseous lesions at two large academic hospital systems. Medical records were queried for the word "incidental," and matches were confirmed by manual review. Patients evaluated at Indiana University Health between January 1, 2014, and December 31, 2020, and those evaluated at University Hospitals between January 1, 2017, and December 31, 2020, were included. All patients were evaluated and treated by the two senior authors of this study and no others were included. Our search identified 625 patients. Sixteen percent (97 of 625) of patients were excluded because their lesions were not incidentally found, and 12% (78 of 625) were excluded because the incidental findings were not bone lesions. Another 4% (24 of 625) were excluded because they had received workup or treatment by an outside orthopaedic oncologist, and 2% (10 of 625) were excluded for missing information. A total of 416 patients were available for preliminary analysis. Among these patients, 33% (136 of 416) were indicated for surveillance. The primary indication for surveillance included lesions with a benign appearance on imaging and low clinical suspicion of malignancy or fracture. A total of 33% (45 of 136) of these patients had less than 12 months of follow-up and were excluded from further analysis. No minimum follow-up criteria were applied to patients not indicated for surveillance because this would artificially inflate our estimated rate of clinically important findings. A total of 371 patients were included in the final study group. Notes from all clinical encounters with orthopaedic and nonorthopaedic providers were screened for our endpoints (biopsy, treatment, or malignancy). Indications for biopsy included lesions with aggressive features, lesions with nonspecific imaging characteristics and a clinical picture concerning for malignancy, and lesion changes seen on imaging during the surveillance period. Indications for treatment included lesions with increased risk of fracture or deformity, certain malignancies, and pathologic fracture. Diagnoses were determined using biopsy results if available or the documented opinion of the consulting orthopaedic oncologist. Imaging reimbursements were obtained from the Medicare Physician Fee Schedule for 2022. Because imaging charges vary across institutions and reimbursements vary across payors, this method was chosen to enhance the comparability of our findings across multiple health systems and studies. RESULTS Seven percent (26 of 371) of incidental findings were determined to be clinically important, as previously defined. Five percent (20 of 371) of lesions underwent tissue biopsy, and 2% (eight of 371) received surgical intervention. Fewer than 2% (six of 371) of lesions were malignant. Serial imaging changed the treatment of 1% (two of 136) of the patients, corresponding to a rate of one in 47 person-years. Median reimbursements to work up the incidental findings analyzed was USD 219 (interquartile range USD 0 to 404), with a range of USD 0 to 890. Among patients indicated for surveillance, the median annual reimbursement was USD 78 (IQR USD 0 to 389), with a range of USD 0 to 2706. CONCLUSION The prevalence of clinically important findings among patients referred to orthopaedic oncology for incidentally found osseous lesions is modest. The likelihood of surveillance resulting in a change of management was low, but the median reimbursements associated with following these lesions was also low. We conclude that after appropriate risk stratification by orthopaedic oncology, incidental lesions are rarely clinically important, and judicious follow-up with serial imaging can be performed without incurring high costs. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Collin W. Blackburn
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Spencer M. Richardson
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert R. DeVita
- Department of Radiology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Oliver Dong
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Navid Faraji
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - L. Daniel Wurtz
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher D. Collier
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick J. Getty
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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5
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Lewis JA, Bonnet K, Schlundt DG, Byerly S, Lindsell CJ, Henschke CI, Yankelevitz DF, York SJ, Hendler F, Dittus RS, Vogus TJ, Kripalani S, Moghanaki D, Audet CM, Roumie CL, Spalluto LB. Rural barriers and facilitators of lung cancer screening program implementation in the veterans health administration: a qualitative study. FRONTIERS IN HEALTH SERVICES 2023; 3:1209720. [PMID: 37674596 PMCID: PMC10477991 DOI: 10.3389/frhs.2023.1209720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/04/2023] [Indexed: 09/08/2023]
Abstract
Introduction To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members. Methods Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation. Results A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior. Discussion Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings.
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Affiliation(s)
- Jennifer A. Lewis
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Qualitative Research Core, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David G. Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Qualitative Research Core, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susan Byerly
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Claudia I. Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States
- Veterans Health Administration—Phoenix VA Health Care System, Radiology Service, Phoenix, AZ, United States
| | - David F. Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States
| | - Sally J. York
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Fred Hendler
- Rex Robley VA Medical Center, Medicine Service, Louisville, KY, United States
| | - Robert S. Dittus
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Timothy J. Vogus
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN, United States
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Drew Moghanaki
- Veterans Health Administration—Greater Los Angeles Veterans Affairs Medical Center, Radiation Oncology Service, Los Angeles, CA, United States
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Carolyn M. Audet
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christianne L. Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lucy B. Spalluto
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
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6
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O'Dowd EL, Lee RW, Akram AR, Bartlett EC, Bradley SH, Brain K, Callister MEJ, Chen Y, Devaraj A, Eccles SR, Field JK, Fox J, Grundy S, Janes SM, Ledson M, MacKean M, Mackie A, McManus KG, Murray RL, Nair A, Quaife SL, Rintoul R, Stevenson A, Summers Y, Wilkinson LS, Booton R, Baldwin DR, Crosbie P. Defining the road map to a UK national lung cancer screening programme. Lancet Oncol 2023; 24:e207-e218. [PMID: 37142382 DOI: 10.1016/s1470-2045(23)00104-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 05/06/2023]
Abstract
Lung cancer screening with low-dose CT was recommended by the UK National Screening Committee (UKNSC) in September, 2022, on the basis of data from trials showing a reduction in lung cancer mortality. These trials provide sufficient evidence to show clinical efficacy, but further work is needed to prove deliverability in preparation for a national roll-out of the first major targeted screening programme. The UK has been world leading in addressing logistical issues with lung cancer screening through clinical trials, implementation pilots, and the National Health Service (NHS) England Targeted Lung Health Check Programme. In this Policy Review, we describe the consensus reached by a multiprofessional group of experts in lung cancer screening on the key requirements and priorities for effective implementation of a programme. We summarise the output from a round-table meeting of clinicians, behavioural scientists, stakeholder organisations, and representatives from NHS England, the UKNSC, and the four UK nations. This Policy Review will be an important tool in the ongoing expansion and evolution of an already successful programme, and provides a summary of UK expert opinion for consideration by those organising and delivering lung cancer screenings in other countries.
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Affiliation(s)
- Emma L O'Dowd
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Richard W Lee
- Early Diagnosis and Detection Centre, National Institute for Health and Care Research Biomedical Research Centre at the Royal Marsden and Institute of Cancer Research, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Ahsan R Akram
- Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK; Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Emily C Bartlett
- Royal Brompton and Harefield Hospitals London and National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Kate Brain
- Division of Population Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | | | - Yan Chen
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Anand Devaraj
- Royal Brompton and Harefield Hospitals London and National Heart and Lung Institute, Imperial College London, London, UK
| | - Sinan R Eccles
- Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, Llantrisant, UK
| | - John K Field
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Jesme Fox
- Roy Castle Lung Cancer Foundation, Liverpool, UK
| | - Seamus Grundy
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Sam M Janes
- Lungs for Living Research Centre, Department of Respiratory Medicine, University College London, London, UK
| | - Martin Ledson
- Department of Respiratory Medicine, Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | | | - Kieran G McManus
- Department of Thoracic Surgery, Royal Victoria Hospital, Belfast, UK
| | - Rachael L Murray
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Arjun Nair
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Samantha L Quaife
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Robert Rintoul
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Anne Stevenson
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
| | - Yvonne Summers
- The Christie Hospital NHS Trust, Manchester University NHS Foundation Trust, Manchester, UK
| | - Louise S Wilkinson
- Oxford Breast Imaging Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Booton
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Philip Crosbie
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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7
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Sayani A, Ali MA, Dey P, Corrado AM, Ziegler C, Nicholson E, Lofters A. Interventions Designed to Increase the Uptake of Lung Cancer Screening: An Equity-Oriented Scoping Review. JTO Clin Res Rep 2023; 4:100469. [PMID: 36938372 PMCID: PMC10015251 DOI: 10.1016/j.jtocrr.2023.100469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities. Methods We conducted a scoping review using the Arksey and O'Malley methodological framework to inform equitable access to LCS by illuminating knowledge and implementation gaps in interventions designed to increase the uptake of LCS. We comprehensively searched for LCS interventions (Ovid Medline, Excerpta Medica database, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus from 2000 to June 22, 2021) and included peer-reviewed articles and gray literature published in the English language that describe an intervention designed to increase the uptake of LCS, charted data using our previously published tool and conduced a health equity analysis to determine the intended-unintended and positive-negative outcomes of the interventions for populations experiencing the greatest inequities. Results Our search yielded 3572 peer-reviewed articles and 54,292 pieces of gray literature. Ultimately, we included 35 peer-reviewed articles and one gray literature. The interventions occurred in the United States, United Kingdom, Japan, and Italy, focusing on shared decision-making, the use of electronic health records as reminders, patient navigation, community-based campaigns, and mobile computed tomography scanners. We developed an equity-oriented LCS framework and mapped the dimensions and outcomes of the interventions on access to LCS on the basis of approachability, acceptability, availability, affordability, and appropriateness of the intervention. No intervention was mapped across all five dimensions. Most notably, knowledge and implementation gaps were identified in dimensions of acceptability, availability, and affordability. Conclusions Interventions that were most effective in improving access to LCS targeted priority populations, raised community-level awareness, tailored materials for sociocultural acceptability, did not depend on prior patient engagement/registration with the health care system, proactively considered costs related to participation, and enhanced utilization through informed decision-making.
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Affiliation(s)
- Ambreen Sayani
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Corresponding author. Address for correspondence: Ambreen Sayani, MD, PhD, Women’s College Research Institute, Women’s College Hospital, 76 Grenville St., Toronto, ON M5S 1B2, Canada.
| | - Muhanad Ahmed Ali
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Pooja Dey
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Ann Marie Corrado
- Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital, Toronto, Ontario, Canada
| | - Carolyn Ziegler
- Library Services, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Aisha Lofters
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
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8
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Pérez-Morales J, Pathak R, Reyes M, Tolbert H, Tirbene R, Gray JE, Simmons VN, Schabath MB, Quinn GP. Qualitative Findings From a Survey on Patient Experiences and Satisfaction with Lung Cancer Screening. Cancer Control 2023; 30:10732748231167963. [PMID: 36971270 PMCID: PMC10052477 DOI: 10.1177/10732748231167963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND To reveal successes and potential limitations of the lung cancer screening program, we conducted a survey that included both quantitative and open-ended questions to measure patient experiences and satisfaction with screening. METHODS We report on the five open-ended items related to barriers to returning for screening, experience with other cancer prevention screenings, positive and negative experiences, and suggestions for improving future appointments. The open-ended responses were analyzed using constant comparison method and inductive content analysis. RESULTS Respondents (182 patients, 86% response rate for open-ended questions) provided generally positive comments about their lung cancer screening experience. Negative comments were related to desire for more information about results, long wait times for results, and billing issues. Suggestions for improvements included: scheduling on-line appointments and text or email reminders, lower costs, and responding to uncertainty about eligibility criteria. CONCLUSION Findings provide insights about patient experiences and satisfaction with lung cancer screening which is important given low uptake. Ongoing patient-centered feedback may improve the lung cancer screening experience and increase follow-up screening rates.
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Affiliation(s)
- Jaileene Pérez-Morales
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Rashmi Pathak
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Monica Reyes
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Haley Tolbert
- Department of Thoracic Oncology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Rajwantee Tirbene
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jhanelle E Gray
- Department of Thoracic Oncology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Vani N Simmons
- Department of Health Outcomes and Behavior, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Matthew B Schabath
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Thoracic Oncology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Gwendolyn P Quinn
- Departments of Obstetrics and Gynecology and Population Health, 12296New York University Grossman School of Medicine, New York, NY, USA
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
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9
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Abstract
Lung cancer is a leading cause of cancer death in the United States and globally with the majority of lung cancer cases attributable to cigarette smoking. Given the high societal and personal cost of a diagnosis of lung cancer including that most cases of lung cancer when diagnosed are found at a late stage, work over the past 40 years has aimed to detect lung cancer earlier when curative treatment is possible. Screening trials using chest radiography and sputum failed to show a reduction in lung cancer mortality however multiple studies using low dose CT have shown the ability to detect lung cancer early and a survival benefit to those screened. This review will discuss the history of lung cancer screening, current recommendations and screening guidelines, and implementation and components of a lung cancer screening program.
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10
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Abstract
Lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer deaths by early detection. The United States Preventive Services Task Force recommends lung cancer screening with LDCT in adults of age 50 years to 80 years who have at least a 20 pack-year smoking history and are currently smoking or have quit within the past 15 years. The implementation of a lung-cancer-screening program is complex. High-quality screening requires the involvement of a multidisciplinary team. The aim of a screening program is to find balance between mortality reduction and avoiding potential harms related to false-positive findings, overdiagnosis, invasive procedures, and radiation exposure. Components and processes of a high-quality lung-cancer-screening program include the identification of eligible individuals, shared decision-making, performing and reporting LDCT results, management of screen-detected lung nodules and non-nodule findings, smoking cessation, ensuring adherence, data collection, and quality improvement.
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Affiliation(s)
- Humberto K Choi
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue Mail Code A90, Cleveland, OH 44195, USA.
| | - Peter J Mazzone
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue Mail Code A90, Cleveland, OH 44195, USA
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11
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Lin YA, Hong YT, Lin XJ, Lin JL, Xiao HM, Huang FF. Barriers and facilitators to uptake of lung cancer screening: A mixed methods systematic review. Lung Cancer 2022; 172:9-18. [PMID: 35963208 DOI: 10.1016/j.lungcan.2022.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/02/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022]
Abstract
Numerous factors contribute to the low adherence to lung cancer screening (LCS) programs. A theory-informed approach to identifying the obstacles and facilitators to LCS uptake is required. This study aimed to identify, assess, and synthesize the available literature at the individual and healthcare provider (HCP) levels based on a social-ecological model and identify gaps to improve practice and policy decision-making. Systematic searches were conducted in nine electronic databases from inception to December 31, 2020. We also searched Google Scholar and manually examined the reference lists of systematic reviews to include relevant articles. Primary studies were scored for quality assessment. Among 3938 potentially relevant articles, 36 studies, including 25 quantitative and 11 qualitative studies, were identified for inclusion in the review. Fifteen common factors were extracted from 34 studies, including nine barriers and six facilitators. The barriers included individual factors (n = 5), health system factors (n = 3), and social/environmental factors (n = 1). The facilitators included only individual factors (n = 6). However, two factors, age and screening harm, remain mixed. This systematic review identified and combined barriers and facilitators to LCS uptake at the individual and HCP levels. The interaction mechanisms among these factors should be further explored, which will allow the construction of tailored LCS recommendations or interventions for the Chinese context.
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Affiliation(s)
- Yu-An Lin
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Yu Ting Hong
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiu Jing Lin
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Jia Ling Lin
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Hui Min Xiao
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Fei Fei Huang
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China.
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12
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Kim RY, Rendle KA, Mitra N, Saia CA, Neslund-Dudas C, Greenlee RT, Burnett-Hartman AN, Honda SA, Simoff MJ, Schapira MM, Croswell JM, Meza R, Ritzwoller DP, Vachani A. Racial Disparities in Adherence to Annual Lung Cancer Screening and Recommended Follow-Up Care: A Multicenter Cohort Study. Ann Am Thorac Soc 2022; 19:1561-1569. [PMID: 35167781 PMCID: PMC9447384 DOI: 10.1513/annalsats.202111-1253oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/14/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Black patients receive recommended lung cancer screening (LCS) follow-up care less frequently than White patients, but it is unknown if this racial disparity persists across both decentralized and centralized LCS programs. Objectives: To determine adherence to American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) recommendations among individuals undergoing LCS at either decentralized or centralized programs and to evaluate the association of race with LCS adherence. Methods: We performed a multicenter retrospective cohort study of patients receiving LCS at five heterogeneous U.S. healthcare systems. We calculated adherence to annual LCS among patients with a negative baseline screen (Lung-RADS 1 or 2) and recommended follow-up care among those with a positive baseline screen (Lung-RADS 3, 4A, 4B, or 4X) stratified by type of LCS program and evaluated the association between race and adherence using multivariable modified Poisson regression. Results: Of the 6,134 total individuals receiving LCS, 5,142 (83.8%) had negative baseline screens, and 992 (16.2%) had positive baseline screens. Adherence to both annual LCS (34.8% vs. 76.1%; P < 0.001) and recommended follow-up care (63.9% vs. 74.6%; P < 0.001) was lower at decentralized compared with centralized programs. Among individuals with negative baseline screens, a racial disparity in adherence was observed only at decentralized screening programs (interaction term, P < 0.001). At decentralized programs, Black race was associated with 27% reduced adherence to annual LCS (adjusted relative risk [aRR], 0.73; 95% confidence interval [CI], 0.63-0.84), whereas at centralized programs, no effect by race was observed (aRR, 0.98; 95% CI, 0.91-1.05). In contrast, among those with positive baseline screens, there was no significant difference by race for adherence to recommended follow-up care by type of LCS program (decentralized aRR, 0.95; 95% CI, 0.81-1.11; centralized aRR, 0.81; 95% CI, 0.71-0.93; interaction term, P = 0.176). Conclusions: In this large multicenter study of individuals screened for lung cancer, adherence to both annual LCS and recommended follow-up care was greater at centralized screening programs. Black patients were less likely to receive annual LCS than White patients at decentralized compared with centralized LCS programs. Our results highlight the need for further study of healthcare system-level mechanisms to optimize longitudinal LCS care.
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Affiliation(s)
- Roger Y. Kim
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health
- Department of Biostatistics, Epidemiology, and Informatics, and
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, and
| | | | | | | | | | - Stacey A. Honda
- Center for Health Research, Kaiser Permanente Hawaii, Oahu, Hawaii
| | - Michael J. Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Marilyn M. Schapira
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer M. Croswell
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, Maryland; and
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | | | - Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
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13
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Strayer TE, Spalluto LB, Burns A, Lindsell CJ, Henschke CI, Yankelevitz DF, Moghanaki D, Dittus RS, Vogus TJ, Audet C, Kripalani S, Roumie CL, Lewis JA. Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study lung cancer screening adaptations in the Veterans Health Administration. RESEARCH SQUARE 2022:rs.3.rs-1862731. [PMID: 35982653 PMCID: PMC9387539 DOI: 10.21203/rs.3.rs-1862731/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Lung cancer screening includes identification of eligible individuals, shared decision-making inclusive of tobacco cessation, and management of screening results. Adaptations to the implemented processes for lung cancer screening in situ are understudied and underreported, with potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for systematic enumeration of adaptations to implementations of evidence-based practices. We used FRAME to study adaptations in lung cancer screening processes that were implemented as part of a Veterans Health Administration (VHA) Enterprise-Wide Initiative. Methods: We conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMC) between 2019-2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, recorded and mapped to FRAME categories. Results: A total of 14 program navigators across 10 VHA lung cancer screening programs participated in 20 interviews. In year 1 (2019-2020), seven programs were operational and of these, three reported adaptations to their screening process that were either planned and in response to COVID-19. In year 2 (2020-2021), all 10 programs were operational. Programs reported 14 adaptations in year 2. These adaptations were both planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 6 of 10 programs to improve the data collection and tracking of Veterans in the screening process. Conclusions: Using FRAME, we found that adaptations occurred throughout the lung cancer screening process but primarily in the areas of patient identification and communication of results. These findings highlight considerations for lung cancer screening implementation and potential areas for future intervention.
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Affiliation(s)
| | | | | | | | | | | | - Drew Moghanaki
- UCLA Health System: University of California Los Angeles Health System
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14
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Rivera MP, Cupertino P, Henderson LM. Complementary Approaches to Lung Cancer Detection in High-Risk Populations. J Clin Oncol 2022; 40:2074-2077. [PMID: 35605172 DOI: 10.1200/jco.22.00494] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/09/2022] [Accepted: 04/18/2022] [Indexed: 12/18/2022] Open
Affiliation(s)
- M Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester, Rochester, NY
- Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | - Paula Cupertino
- Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | - Louise M Henderson
- Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill, NC
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
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15
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Beyond the AJR: Disparities in Lung Cancer Screening Adherence Persist in the Veterans Health Administration. AJR Am J Roentgenol 2022:1. [PMID: 35234498 DOI: 10.2214/ajr.21.26852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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16
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Spalluto LB, Lewis JA, Samuels LR, Callaway-Lane C, Matheny ME, Denton J, Robles JA, Dittus RS, Yankelevitz DF, Henschke CI, Massion PP, Moghanaki D, Roumie CL. Association of Rurality With Annual Repeat Lung Cancer Screening in the Veterans Health Administration. J Am Coll Radiol 2022; 19:131-138. [PMID: 35033300 PMCID: PMC8830608 DOI: 10.1016/j.jacr.2021.08.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Lung cancer causes the largest number of cancer-related deaths in the United States. Lung cancer incidence rates, mortality rates, and rates of advanced stage disease are higher among those who live in rural areas. Known disparities in lung cancer outcomes between rural and nonrural populations may be in part because of barriers faced by rural populations. The authors tested the hypothesis that among Veterans who receive initial lung cancer screening, rural Veterans would be less likely to complete annual repeat screening than nonrural Veterans. METHODS A retrospective cohort study was conducted of 10 Veterans Affairs medical centers from 2015 to 2019. Rural and nonrural Veterans undergoing lung cancer screening were identified. Rural status was defined using the rural-urban commuting area codes. The primary outcome was annual repeat lung cancer screening in the 9- to 15-month window (primary analysis) and 31-day to 18-month window (sensitivity analysis) after the first documented lung cancer screening. To examine rurality as a predictor of annual repeat lung cancer screening, multivariable logistic regression models were used. RESULTS In the final analytic sample of 11,402 Veterans, annual repeat lung cancer screening occurred in 27.7% of rural Veterans (641 of 2,316) and 31.8% of nonrural Veterans (2,891 of 9,086) (adjusted odds ratio: 0.86; 95% confidence interval: 0.73-1.03). Similar results were seen in the sensitivity analysis, with 41.6% of rural Veterans (963 of 2,316) versus 45.2% of nonrural Veterans (4,110 of 9,086) (adjusted odds ratio: 0.88; 95% confidence interval: 0.73-1.04) having annual repeat screening in the expanded 31-day to 18-month window. CONCLUSIONS Among a national cohort of Veterans, rural residence was associated with numerically lower odds of annual repeat lung cancer screening than nonrural residence. Continued, intentional outreach efforts to increase annual repeat lung cancer screening among rural Veterans may offer an opportunity to decrease deaths from lung cancer.
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Affiliation(s)
- Lucy B. Spalluto
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Radiology, Vanderbilt University Medical Center, Nashville, TN,Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jennifer A. Lewis
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Vanderbilt-Ingram Cancer Center, Nashville, TN,Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Lauren R. Samuels
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Carol Callaway-Lane
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN
| | - Michael E. Matheny
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Jason Denton
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Jennifer A. Robles
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Veterans Health Administration – Tennessee Valley Healthcare System, Surgery Service, Nashville, TN,Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Robert S. Dittus
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | | | - Claudia I. Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,Phoenix Veterans Health Care System, Phoenix, AZ
| | - Pierre P. Massion
- Vanderbilt-Ingram Cancer Center, Nashville, TN,Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN,Veterans Health Administration – Tennessee Valley Healthcare System, Medical Service, Nashville, TN
| | - Drew Moghanaki
- Radiation Oncology, Greater Los Angeles Veterans Affairs Medical Center, Los Angeles, CA,Department of Radiation Oncology, University of California at Los Angeles, Los Angeles, CA
| | - Christianne L. Roumie
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
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17
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Gillespie C, Wiener RS, Clark JA. Patient Experience of Managing Adherence to Repeat Lung Cancer Screening. J Patient Exp 2022; 9:23743735221126146. [PMID: 36187210 PMCID: PMC9515519 DOI: 10.1177/23743735221126146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Lung cancer screening (LCS) is a process involving multiple low-dose computed tomography (LDCT) scans over multiple years. While adherence to recommended follow-up is critical in reducing lung cancer mortality, little is known about factors influencing adherence following the initial LDCT scan. The purpose of this study was to examine patients’ and providers’ depictions of continued screening and their understandings of patients’ decisions to return for follow-up. Qualitative methodology involves interviews with patients about their understanding of the screening process and perceptions of lung cancer risk, including motivations to adhere to follow-up screening and surveillance. Analysis of interview transcripts followed the general procedures of grounded theory methodology. Patient adherence to LCS was influenced by their understanding of the process of screening, and their expectations for the next steps. Perceptions of lung cancer risk and associated motivation were not static and changed throughout the screening process. Recognizing that patients’ motivations may be dynamic over the course of screening and surveillance will assist providers in helping patients make decisions regarding continued engagement with LCS.
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Affiliation(s)
- Chris Gillespie
- Center for HealthCare Organization and Implementation Research (CHOIR), Bedford VA Medical Center, Bedford, MA, USA
| | - Renda Soylemez Wiener
- Center for HealthCare Organization and Implementation Research (CHOIR), Bedford VA Medical Center, Bedford, MA, USA
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Jack A Clark
- Dept. of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
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18
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Byrne SC, Hammer MM. Use of Diagnostic CT and Patient Retention in a Lung Cancer Screening Program. J Am Coll Radiol 2021; 19:47-52. [PMID: 34752759 DOI: 10.1016/j.jacr.2021.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/06/2021] [Accepted: 09/13/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE The aims of this study were to assess the rate of subsequent diagnostic chest CT examinations in a lung cancer screening (LCS) program and examine the effect on retention of patients in the program. METHODS Patients who underwent LCS CT between June 2011 and August 2018 were included. The occurrence of patients' being subsequently imaged with diagnostic CT versus LCS CT and the effect this had on patients' returning for LCS CT (patient retention) were evaluated. Multivariable logistic regression was used to evaluate variables associated with undergoing diagnostic CT and risk factors associated with loss of patient retention. RESULTS Of the 5,912 patients who underwent LCS CT, 2,756 underwent subsequent diagnostic or LCS chest CT. Increasing Lung-RADS® score was more likely to lead to subsequent diagnostic chest CT (P < .0001). A total of 1,240 patients underwent at least three chest CT examinations in the time interval. For the 711 patients whose subsequent CT studies were for LCS, 585 (82%) were retained, whereas of the 529 patients who underwent subsequent diagnostic CT, only 208 (39%) were retained (P < .0001). For the 197 subsequent diagnostic CT examinations performed for pulmonary nodule or screening indications, 81 patients (41%) returned for LCS CT, compared with 498 of 612 patients (81%) who underwent subsequent LCS CT (P < .0001). In multivariable analysis, subsequent diagnostic chest CT and increasing Lung-RADS score were associated with loss of retention. CONCLUSIONS A higher Lung-RADS score is a risk factor for subsequent diagnostic chest CT, and this is an independent risk factor for loss from the LCS program.
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Affiliation(s)
- Suzanne C Byrne
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Mark M Hammer
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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19
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Mazzone PJ, Silvestri GA, Souter LH, Caverly TJ, Kanne JP, Katki HA, Wiener RS, Detterbeck FC. Screening for Lung Cancer: CHEST Guideline and Expert Panel Report. Chest 2021; 160:e427-e494. [PMID: 34270968 PMCID: PMC8727886 DOI: 10.1016/j.chest.2021.06.063] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/11/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Low-dose chest CT screening for lung cancer has become a standard of care in the United States, in large part because of the results of the National Lung Screening Trial (NLST). Additional evidence supporting the net benefit of low-dose chest CT screening for lung cancer, and increased experience in minimizing the potential harms, has accumulated since the prior iteration of these guidelines. Here, we update the evidence base for the benefit, harms, and implementation of low-dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not. METHODS Approved panelists reviewed previously developed key questions using the Population, Intervention, Comparator, Outcome format to address the benefit and harms of low-dose CT screening, and key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. Reference lists from relevant retrievals were searched, and additional papers were added. Retrieved references were reviewed for relevance by two panel members. The quality of the evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analyses were performed when enough evidence was available. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and ungraded statements were drafted, voted on, and revised until consensus was reached. RESULTS The systematic literature review identified 75 additional studies that informed the response to the 12 key questions that were developed. Additional clinical questions were addressed resulting in seven graded recommendations and nine ungraded consensus statements. CONCLUSIONS Evidence suggests that low-dose CT screening for lung cancer can result in a favorable balance of benefit and harms. The selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen-detected findings, and the effectiveness of smoking cessation interventions can impact this balance.
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Affiliation(s)
| | | | | | - Tanner J Caverly
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; University of Michigan Medical School, Ann Arbor, MI
| | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA; Boston University School of Medicine, Boston, MA
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20
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Lin Y, Fu M, Ding R, Inoue K, Jeon CY, Hsu W, Aberle DR, Prosper AE. Patient Adherence to Lung CT Screening Reporting & Data System-Recommended Screening Intervals in the United States: A Systematic Review and Meta-Analysis. J Thorac Oncol 2021; 17:38-55. [PMID: 34624528 PMCID: PMC8692358 DOI: 10.1016/j.jtho.2021.09.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/22/2021] [Accepted: 09/25/2021] [Indexed: 12/21/2022]
Abstract
Lung cancer screening (LCS) is effective in reducing mortality, particularly when patients adhere to follow-up recommendations standardized by the Lung CT Screening Reporting & Data System (Lung-RADS). Nevertheless, patient adherence to recommended intervals varies, potentially diminishing benefit from screening. We conducted a systematic review and meta-analysis of patient adherence to Lung-RADS-recommended screening intervals. We systematically searched MEDLINE, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials, and major radiology and oncology conference archives between April 28, 2014, and December 17, 2020. Eligible studies mentioned patient adherence to the recommendations of Lung-RADS. The review protocol was registered with PROSPERO (CRD42020189326). We identified 24 eligible studies for qualitative summary, of which 21 were suitable for meta-analysis. The pooled adherence rate was 57% (95% confidence interval: 46%-69%) for defined adherence (e.g., an annual incidence screen was performed within 15 mo) among 6689 patients and 65% (95% confidence interval: 55%-75%) for anytime adherence among 5085 patients. Large heterogeneity in adherence rates between studies was observed (I2 = 99% for defined adherence, I2 = 98% for anytime adherence). Heterogeneous adherence rates were associated with Lung-RADS scores, with significantly higher adherence rates among Lung-RADS 3 to 4 than Lung-RADS 1 to 2 (p < 0.05). Patient adherence to Lung-RADS-recommended screening intervals is suboptimal across clinical LCS programs in the United States, especially among patients with results of Lung-RADS categories 1 to 2. To improve adherence rates, future research may focus on implementing tailored interventions after identifying barriers to LCS. We also propose a minimum standardized set of data elements for future pooled analyses of LCS adherence on the basis of our findings.
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Affiliation(s)
- Yannan Lin
- Department of Bioengineering, University of California Los Angeles, Los Angeles, California; Medical & Imaging Informatics Group, Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California.
| | - Mingzhou Fu
- Medical Informatics Home Area, Department of Bioinformatics, University of California Los Angeles, Los Angeles, California
| | - Ruiwen Ding
- Department of Bioengineering, University of California Los Angeles, Los Angeles, California; Medical & Imaging Informatics Group, Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California
| | - Kosuke Inoue
- Department of Social Epidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Christie Y Jeon
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California; Department of Medicine, Samuel Oschin Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - William Hsu
- Department of Bioengineering, University of California Los Angeles, Los Angeles, California; Medical & Imaging Informatics Group, Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California
| | - Denise R Aberle
- Department of Bioengineering, University of California Los Angeles, Los Angeles, California; Medical & Imaging Informatics Group, Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California; Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ashley Elizabeth Prosper
- Medical & Imaging Informatics Group, Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California; Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
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21
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Kunitomo Y, Bade B, Gunderson CG, Akgün KM, Brackett A, Cain H, Tanoue L, Bastian LA. Racial Differences in Adherence to Lung Cancer Screening Follow-Up: A Systematic Review and Meta-Analysis. Chest 2021; 161:266-275. [PMID: 34390706 DOI: 10.1016/j.chest.2021.07.2172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/17/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND In 2013 the United States Preventive Services Taskforce (USPSTF) instituted recommendations for annual lung cancer screening (LCS) with low dose chest computed tomography for high-risk individuals. LCS reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality have been well documented, less is known about disparities in LCS participation and adherence to follow-up in clinical practice. RESEARCH QUESTION What is the association between race and adherence to LCS follow-up? STUDY DESIGN & METHODS A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature Database, from database inception through October 2020. We included studies that examined rates of adherence to LCS follow-up and compared rates by race. Studies were pooled using random-effects meta-analysis. RESULTS We screened 18,300 titles/abstracts and 229 studies were selected for full-text review. Nine studies met inclusion criteria; seven were included in the meta-analysis. Median adherent follow-up rate was 37% (range 16-82%). Notable differences among the studies included the proportion of the Black population (range 4-47%) and the structure of the LCS programs. The meta-analyses showed lower adherence to LCS follow-up in the Black population (Odds Ratio [OR]=0.67, [95% CI: 0.55, 0.80]). This disparity persisted across all malignancy risk levels determined by initial screening results. INTERPRETATION There is lower adherence to LCS follow-up in Black compared to White patients despite the higher potential lung cancer mortality benefit. Literature specifically addressing race-related barriers to LCS adherence is still limited. To ensure equity in LCS benefits, greater outreach to eligible Black patients should be implemented through increased physician education and utilization of screening program coordinators to focus on this patient population.
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Affiliation(s)
- Yukiko Kunitomo
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Brett Bade
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Craig G Gunderson
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Kathleen M Akgün
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, United States
| | - Hilary Cain
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Lynn Tanoue
- Yale School of Medicine, New Haven, Connecticut, United States
| | - Lori A Bastian
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States.
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22
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Hirsch EA, Barón AE, Risendal B, Studts JL, New ML, Malkoski SP. Determinants Associated With Longitudinal Adherence to Annual Lung Cancer Screening: A Retrospective Analysis of Claims Data. J Am Coll Radiol 2021; 18:1084-1094. [PMID: 33798496 PMCID: PMC8349785 DOI: 10.1016/j.jacr.2021.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Lung cancer screening (LCS) efficacy is highly dependent on adherence to annual screening, but little is known about real-world adherence determinants. We used insurance claims data to examine associations between LCS annual adherence and demographic, comorbidity, health care usage, and geographic factors. MATERIALS AND METHODS Insurance claims data for all individuals with an LCS low-dose CT scan were obtained from the Colorado All Payer Claims Dataset. Adherence was defined as a second claim for a screening CT 10 to 18 months after the index claim. Cox proportional hazards regression was used to define the relationship between annual adherence and age, gender, insurance type, residence location, outpatient health care usage, and comorbidity burden. RESULTS After exclusions, the final data set consisted of 9,056 records with 3,072 adherent, 3,570 nonadherent, and 2,414 censored (unclassifiable) individuals. Less adherence was associated with ages 55 to 59 (hazard ratio [HR] = 0.80, 99% confidence interval [CI] = 0.67-0.94), 60 to 64 (HR = 0.83, 99% CI = 0.71-0.97), and 75 to 79 (HR = 0.79, 99% CI = 0.65-0.97); rural residence (HR = 0.56, 99% CI = 0.43-0.73); Medicare fee-for-service (HR = 0.45, 99% CI = 0.39-0.51), and Medicaid (HR = 0.50, 99% CI = 0.40-0.62). A significant interaction between outpatient health care usage and comorbidity was also observed. Increased outpatient usage was associated with increased adherence and was most pronounced for individuals without comorbidities. CONCLUSIONS This population-based description of LCS adherence determinants provides insight into populations that might benefit from specific interventions targeted toward improving adherence and maximizing LCS benefit. Quantifying population-based adherence rates and understanding factors associated with annual adherence are critical to improving screening adherence and reducing lung cancer death.
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Affiliation(s)
- Erin A Hirsch
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anna E Barón
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Betsy Risendal
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jamie L Studts
- Division of Medical Oncology and Cancer Prevention and Control Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Melissa L New
- Pulmonary Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stephen P Malkoski
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, University of Washington, WWAMI-Spokane, Spokane, Washington; Sound Critical Care, Sacred Heart Medical Center, Spokane, Washington.
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23
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Mazzone PJ, Silvestri GA, Souter LH, Caverly TJ, Kanne JP, Katki HA, Wiener RS, Detterbeck FC. Screening for Lung Cancer: CHEST Guideline and Expert Panel Report - Executive Summary. Chest 2021; 160:1959-1980. [PMID: 34270965 DOI: 10.1016/j.chest.2021.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Low-dose chest CT screening for lung cancer has become a standard of care in the United States, in large part due to the results of the National Lung Screening Trial. Additional evidence supporting the net benefit of low-dose chest CT screening for lung cancer, as well as increased experience in minimizing the potential harms, has accumulated since the prior iteration of these guidelines. Here, we update the evidence base for the benefit, harms, and implementation of low-dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not. METHODS Approved panelists reviewed previously developed key questions using the PICO (population, intervention, comparator, and outcome) format to address the benefit and harms of low-dose CT screening, as well as key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. Reference lists from relevant retrievals were searched, and additional papers were added. Retrieved references were reviewed for relevance by two panel members. The quality of the evidence was assessed for each critical or important outcome of interest using the GRADE approach. Meta-analyses were performed where appropriate. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and un-graded statements were drafted, voted on, and revised until consensus was reached. RESULTS The systematic literature review identified 75 additional studies that informed the response to the 12 key questions that were developed. Additional clinical questions were addressed resulting in 7 graded recommendations and 9 ungraded consensus statements. CONCLUSIONS Evidence suggests that low-dose CT screening for lung cancer can result in a favorable balance of benefit and harms. The selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen detected findings, and the effectiveness of smoking cessation interventions, can impact this balance.
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Affiliation(s)
| | | | | | - Tanner J Caverly
- Ann Arbor VA Center for Clinical Management Research and University of Michigan Medical School , Madison, WI
| | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System and Boston University School of Medicine, Boston, MA
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24
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Núñez ER, Caverly TJ, Zhang S, Glickman ME, Qian SX, Boudreau JH, Slatore CG, Miller DR, Wiener RS. Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019. JAMA Netw Open 2021; 4:e2116233. [PMID: 34236409 PMCID: PMC8267608 DOI: 10.1001/jamanetworkopen.2021.16233] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs. OBJECTIVE To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020. MAIN OUTCOMES AND MEASURES Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims. RESULTS Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions. CONCLUSIONS AND RELEVANCE In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.
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Affiliation(s)
- Eduardo R. Núñez
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Tanner J. Caverly
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan School of Medicine, Ann Arbor
| | - Sanqian Zhang
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Mark E. Glickman
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Shirley X. Qian
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Jacqueline H. Boudreau
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Donald R. Miller
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
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25
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"It's Really Like Any Other Study": Rural Radiology Facilities Performing Low-Dose Computed Tomography for Lung Cancer Screening. Ann Am Thorac Soc 2021; 18:2058-2066. [PMID: 34129451 DOI: 10.1513/annalsats.202103-333oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE The majority of eligible people have not been screened for lung cancer. There is emerging evidence that there are location-based disparities applicable to lung cancer screening. OBJECTIVE Describe lung cancer screening radiologic services in rural Oregon and understand the barriers and facilitators to implementation of lung cancer screening using LDCT. METHODS A mixed-methods descriptive study utilizing surveys and semi-structured interviews of key informants. We approached representatives from all 37 small and rural hospitals in Oregon. We purposively interviewed key informants from a sub-set based on LDCT implementation outcomes. RESULTS We surveyed representatives from 29 radiology facilities and qualitatively interviewed 18 key informants from 19 facilities (representing 12 health care systems). Among the surveyed radiology facilities, 59% were performing LDCT for lung cancer screening. Key informants reported that facilities which performed this service were often motivated by community needs, less by financial gain or evidence strength and all described the importance of a champion. Key informants described that implementing lung cancer screening programmatic components that were within their normal scope of practice (e.g. specifying the LDCT parameters) were burdensome to establish but were surmountable barriers. Most informants reported they did not perform other components of high-quality programs (e.g. ensuring adherence to recommended follow-up testing) and suggested these steps were important but the responsibility of primary care providers. CONCLUSIONS Many rural hospital facilities in Oregon offer LDCT for lung cancer screening, but do not perform all the recommended components of a screening program. Disparities in lung cancer screening utilization and adherence are unlikely to be solved by an exclusive focus at the radiology facility level and may require additional interventions at the primary care level.
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Erkmen CP, Randhawa S, Patterson F, Kim R, Weir M, Ma GX. Quantifying Benefits and Harms of Lung Cancer Screening in an Underserved Population: Results From a Prospective Study. Semin Thorac Cardiovasc Surg 2021; 34:691-700. [PMID: 34091014 DOI: 10.1053/j.semtcvs.2021.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/17/2022]
Abstract
Lung cancer screening with annual low-dose computed tomography reduces lung cancer death by 20-26%. However, potential harms of screening include false-positive results, procedures from false positives, procedural complications and failure to adhere to follow-up recommendations. In diverse, underserved populations, it is unknown if benefits of early lung cancer detection outweigh harms. We conducted a prospective observational study of lung cancer screening participants in an urban, safety-net institution from September 2014 to June 2020. We measured benefits of screening in terms of cancer diagnosis, stage, and treatment. We measured harms of screening by calculating false-positive rate, procedures as a result of false positive screens, procedural complications, and failure to follow-up with recommended care. Of patients with 3-year follow up, we measured these same outcomes in addition to compliance with annual screening. Of 1509 participants, 55.6% were African American, 35.2% White, 8.1% Hispanic, and 0.5% Asian. Screening resulted in cancer detection and treatment in 2.8%. False positive and procedure as a result of a false positive occurred in 9.2% and 0.8% of participants, respectively with no major complications from diagnostic procedures or treatment. Adherence to annual screening was low, 18.7%, 3.7%, and 0.4% at 1, 2, and 3 years after baseline screening respectively. Multidisciplinary lung cancer screening in a safety-net institution can successfully detect and treat lung cancer with few harms of false-positive screens, procedure after false-positive screens and major complications. However, adherence to annual screening is poor.
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Affiliation(s)
- Cherie P Erkmen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Philadelphia, Pennsylvania.
| | - Simran Randhawa
- Department of Thoracic Surgery, Washington University, St. Louis, Missouri
| | - Freda Patterson
- University of Delaware, Behavioral Health and Nutrition, Newark, Delaware
| | - Rachel Kim
- Department of Surgery, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Mark Weir
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Grace X Ma
- Center for Asian Health, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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Mortman KD, Devlin J, Giang B, Mortman R, Sparks AD, Napolitano MA. Patient Adherence in an Academic Medical Center's Low-dose Computed Tomography Screening Program. Am J Clin Oncol 2021; 44:264-268. [PMID: 33795600 DOI: 10.1097/coc.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Low-dose computed tomography (LDCT) screening is an important tool for reducing lung cancer mortality. This study describes a single center's experience with LDCT and attempts to identify any barriers to compliance with standard guidelines. MATERIALS AND METHODS This is a retrospective review of a single university-based hospital system from 2015 to 2019. All individuals who met eligibility for lung cancer screening were entered into a database. The definition of adherence with the screening program was determined by the recommended timeline for the follow-up LDCT. Cohorts were split by adherence and demographics were compared. RESULTS A total of 203 LDCTs were performed in 121 patients who met eligibility for LDCT and had appropriate surveillance from 2015 to 2019. The average age was 64 years old. The overall adherence rate for prescribed LDCTs was 59.1%. Patients with Lung-RADS score 2 had 2.43 times higher odds of adherence relative to patients with Lung-RADS score 1 (odds ratio [OR]=2.43; 95% confidence interval [CI]: 1.23-4.83; P=0.011). African American patients had 42% lower odds of adherence relative to white patients (OR=0.58; 95% CI: 0.32-1.06; P=0.076). Patients with non-District of Columbia zip codes had 57% higher odds of adherence relative to those with District of Columbia zip codes, although this did not reach statistical significance (OR=1.57; 95% CI: 0.87-2.82; P=0.136). CONCLUSIONS Despite the implementation of a multidisciplinary, academic LDCT screening program, overall adherence rate to prescribed follow-up scans was suboptimal. Socioeconomic disparities and African American race may negatively affect adherence to lung cancer screening LDCT guidelines. Patients with concerning findings on initial LDCT had a higher association of adherence to guidelines.
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Affiliation(s)
- Keith D Mortman
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital
| | - Joseph Devlin
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital
| | - Brian Giang
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Ryan Mortman
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Andrew D Sparks
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital
| | - Michael A Napolitano
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital
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Sakoda LC, Rivera MP, Zhang J, Perera P, Laurent CA, Durham D, Huamani Velasquez R, Lane L, Schwartz A, Quesenberry CP, Minowada G, Henderson LM. Patterns and Factors Associated With Adherence to Lung Cancer Screening in Diverse Practice Settings. JAMA Netw Open 2021; 4:e218559. [PMID: 33929519 PMCID: PMC8087957 DOI: 10.1001/jamanetworkopen.2021.8559] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE For lung cancer screening to confer mortality benefit, adherence to annual screening with low-dose computed tomography scans is essential. Although the National Lung Screening Trial had an adherence rate of 95%, current data are limited on screening adherence across diverse practice settings in the United States. OBJECTIVE To evaluate patterns and factors associated with adherence to annual screening for lung cancer after negative results of a baseline examination, particularly in centralized vs decentralized screening programs. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study was conducted at 5 academic and community-based sites in North Carolina and California among 2283 individuals screened for lung cancer between July 1, 2014, and March 31, 2018, who met US Preventive Services Task Force eligibility criteria, had negative results of a baseline screening examination (American College of Radiology Lung Imaging Reporting and Data System category 1 or 2), and were eligible to return for a screening examination in 12 months. EXPOSURES To identify factors associated with adherence, the association of adherence with selected baseline demographic and clinical characteristics, including type of screening program, was estimated using multivariable logistic regression. Screening program type was classified as centralized if individuals were referred through a lung cancer screening clinic or program and as decentralized if individuals had a direct clinician referral for the baseline low-dose computed tomography scan. MAIN OUTCOMES AND MEASURES Adherence to annual lung cancer screening, defined as a second low-dose computed tomography scan within 11 to 15 months after baseline screening. RESULTS Among the 2283 eligible individuals (1294 men [56.7%]; mean [SD] age, 64.9 [5.8] years; 1160 [50.8%] aged ≥65 years) who had negative screening results at baseline, overall adherence was 40.2% (n = 917), with higher adherence among those who underwent screening through centralized (46.0% [478 of 1039]) vs decentralized (35.3% [439 of 1244]) programs. The independent factor most strongly associated with adherence was type of screening program, with a 2.8-fold increased likelihood of adherence associated with centralized screening (adjusted odds ratio [aOR], 2.78; 95% CI, 1.99-3.88). Another associated factor was age (65-69 vs 55-59 years: aOR, 1.38; 95% CI, 1.07-1.77; 70-74 vs 55-59 years: aOR, 1.47; 95% CI, 1.10-1.96). CONCLUSIONS AND RELEVANCE After negative results of a baseline examination, adherence to annual lung cancer screening was suboptimal, although adherence was higher among individuals who were screened through a centralized program. These results support the value of centralized screening programs and the need to further implement strategies that improve adherence to annual screening for lung cancer.
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Affiliation(s)
- Lori C. Sakoda
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - M. Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Jie Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Pasangi Perera
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Cecile A. Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Danielle Durham
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Lindsay Lane
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Adam Schwartz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - George Minowada
- Department of Pulmonary Medicine, Kaiser Permanente Northern California, Vallejo
| | - Louise M. Henderson
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill
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Abstract
It may seem unlikely that the field of radiology perpetuates disparities in health care, as most radiologists never interact directly with patients, and racial bias is not an obvious factor when interpreting images. However, a closer look reveals that imaging plays an important role in the propagation of disparities. For example, many advanced and resource-intensive imaging modalities, such as MRI and PET/CT, are generally less available in the hospitals frequented by people of color, and when they are available, access is impeded due to longer travel and wait times. Furthermore, their images may be of lower quality, and their interpretations may be more error prone. The aggregate effect of these imaging acquisition and interpretation disparities in conjunction with social factors is insufficiently recognized as part of the wide variation in disease outcomes seen between races in America. Understanding the nature of disparities in radiology is important to effectively deploy the resources and expertise necessary to mitigate disparities through diversity and inclusion efforts, research, and advocacy. In this article, the authors discuss disparities in access to imaging, examine their causes, and propose solutions aimed at addressing these disparities.
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Affiliation(s)
- Stephen Waite
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
| | - Jinel Scott
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
| | - Daria Colombo
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
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Rivera MP, Katki HA, Tanner NT, Triplette M, Sakoda LC, Wiener RS, Cardarelli R, Carter-Harris L, Crothers K, Fathi JT, Ford ME, Smith R, Winn RA, Wisnivesky JP, Henderson LM, Aldrich MC. Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement. Am J Respir Crit Care Med 2020; 202:e95-e112. [PMID: 33000953 PMCID: PMC7528802 DOI: 10.1164/rccm.202008-3053st] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.
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Lopez-Olivo MA, Maki KG, Choi NJ, Hoffman RM, Shih YCT, Lowenstein LM, Hicklen RS, Volk RJ. Patient Adherence to Screening for Lung Cancer in the US: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e2025102. [PMID: 33196807 PMCID: PMC7670313 DOI: 10.1001/jamanetworkopen.2020.25102] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/13/2020] [Indexed: 12/19/2022] Open
Abstract
Importance To be effective in reducing deaths from lung cancer among high-risk current and former smokers, screening with low-dose computed tomography must be performed periodically. Objective To examine lung cancer screening (LCS) adherence rates reported in the US, patient characteristics associated with adherence, and diagnostic testing rates after screening. Data Sources Five electronic databases (MEDLINE, Embase, Scopus, CINAHL, and Web of Science) were searched for articles published in the English language from January 1, 2011, through February 28, 2020. Study Selection Two reviewers independently selected prospective and retrospective cohort studies from 95 potentially relevant studies reporting patient LCS adherence. Data Extraction and Synthesis Quality appraisal and data extraction were performed independently by 2 reviewers using the Newcastle-Ottawa Scale for quality assessment. A random-effects model meta-analysis was conducted when at least 2 studies reported on the same outcome. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guideline. Main Outcomes and Measures The primary outcome was LCS adherence after a baseline screening. Secondary measures were the patient characteristics associated with adherence and the rate of diagnostic testing after screening. Results Fifteen studies with a total of 16 863 individuals were included in this systematic review and meta-analysis. The pooled LCS adherence rate across all follow-up periods (range, 12-36 months) was 55% (95% CI, 44%-66%). Regarding patient characteristics associated with adherence rates, current smokers were less likely to adhere to LCS than former smokers (odds ratio [OR], 0.70; 95% CI, 0.62-0.80); White patients were more likely to adhere to LCS than patients of races other than White (OR, 2.0; 95% CI, 1.6-2.6); people 65 to 73 years of age were more likely to adhere to LCS than people 50 to 64 years of age (OR, 1.4; 95% CI, 1.0-1.9); and completion of 4 or more years of college was also associated with increased adherence compared with people not completing college (OR, 1.5; 95% CI, 1.1-2.1). Evidence was insufficient to evaluate diagnostic testing rates after abnormal screening scan results. The main source of variation was attributable to the eligibility criteria for screening used across studies. Conclusions and Relevance In this study, the pooled LCS adherence rate after a baseline screening was far lower than those observed in large randomized clinical trials of screening. Interventions to promote adherence to screening should prioritize current smokers and smokers from minority populations.
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Affiliation(s)
- Maria A. Lopez-Olivo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Kristin G. Maki
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Noah J. Choi
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Richard M. Hoffman
- Department of Internal Medicine, The Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, Iowa City
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Lisa M. Lowenstein
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Rachel S. Hicklen
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston
| | - Robert J. Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
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Stowell JT, Narayan AK, Wang GX, Fintelmann FJ, Flores EJ, Sharma A, Petranovic M, Shepard JAO, Little BP. Factors affecting patient adherence to lung cancer screening: A multisite analysis. J Med Screen 2020; 28:357-364. [PMID: 32847462 DOI: 10.1177/0969141320950783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify factors associated with delayed adherence to follow-up in lung cancer screening. METHODS Utilizing a data warehouse and lung cancer screening registry, variables were collected from a referred sample of 3110 unique participants with follow-up CT during the study period (1 January 2016 to 17 October 2018). Adherence was defined as undergoing chest CT within 90 days and 30 days of the recommended time for follow-up and was determined using proportions and multiple variable logistic regression models across the American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS®) categories. RESULTS Of 1954 lung cancer screening participants (51.9% (1014/1954) males, 48.1% (940/1954) female; mean age 65.7 (range 45-87), smoking history median 40 pack-years, 60.2% and 44.5% did not follow-up within 30 and 90 days, respectively. Participants receiving Lung-RADS® category 1 or 2 presented later than those with Lung-RADS® category 3 at 90 days (coefficient -27.24, 95% CI -51.31, -3.16, p = 0.027). Participants with Lung-RADS® category 1 presented later than those with Lung-RADS® category 2 at both 90- and 30-days past due (OR 0.76 95% CI [0.59-0.97], p = 0.029 and OR 0.63 95% CI [0.48-0.83], p = 0.001, respectively). CONCLUSIONS Adherence to follow-up was higher among participants receiving more suspicious Lung-RADS® results at index screening CT and among those who had undergone more non-lung cancer screening imaging examinations prior to index lung cancer screening CT. These observations may inform strategies aimed at prospectively identifying participants at risk for delayed or nonadherence to prevent potential morbidity and mortality from incident lung cancers.
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Affiliation(s)
| | - Anand K Narayan
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Gary X Wang
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Efren J Flores
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Amita Sharma
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Milena Petranovic
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jo-Anne O Shepard
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Brent P Little
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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Lam AC, Aggarwal R, Cheung S, Stewart EL, Darling G, Lam S, Xu W, Liu G, Kavanagh J. Predictors of participant nonadherence in lung cancer screening programs: a systematic review and meta-analysis. Lung Cancer 2020; 146:134-144. [DOI: 10.1016/j.lungcan.2020.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/03/2020] [Accepted: 05/09/2020] [Indexed: 02/06/2023]
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Febbo J, Little B, Fischl-Lanzoni N, Narayan AK, Tiersma KM, Glover M, Shepard JAO, Flores EJ. Analysis of Out-of-Pocket Cost of Lung Cancer Screening for Uninsured Patients Among ACR-Accredited Imaging Centers. J Am Coll Radiol 2020; 17:1108-1115. [PMID: 32278848 DOI: 10.1016/j.jacr.2020.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine the variability in out-of-pocket costs of lung cancer screening (LCS) for uninsured patients and assess accessibility of this information by telephone or Internet. METHODS LCS centers from the ACR's LCS database were randomly selected. Centers were called between July and August 2019 to determine out-of-pocket cost. Telephone call variables, accessibility of cost information on screening centers' websites, screening centers' chargemasters, and publicly available facility and state insurance coverage variables were obtained. Cost information was summarized using descriptive analyses. Multiple variable linear regression analyses were conducted to evaluate effects of facility and state-level characteristics on out-of-pocket costs. RESULTS Fifty-five ACR-accredited LCS centers were included with 78% (43 of 55) willing to provide out-of-pocket cost. Average out-of-pocket cost was $583 ± $607 (mean ± standard deviation), range $49 to $2,409. Average telephone call length 6 ± 3.8 min. Two of fifty-five screening centers' websites provided out-of-pocket cost information, and one matched cost given over the telephone. A chargemaster was found for 30 of 55 screening centers. No statistically significant differences in out-of-pocket costs were found by geographic region, state percentages of uninsured residents, state percentages of residents with public insurance, or facility safety net hospital affiliation. DISCUSSION Out-of-pocket LCS costs for uninsured patients and availability of this information is highly variable. Radiology practices should be aware of this variability that may influence participation rates among uninsured patients.
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Affiliation(s)
- Jennifer Febbo
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brent Little
- Harvard Medical School, Boston, Massachusetts; Associate Residency Program Director, Massachusetts General Hospital, Boston, Massachusetts
| | - Natalia Fischl-Lanzoni
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anand K Narayan
- Co-Chair, Diversity, Equity and Inclusion Committee, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Massachusetts General Physicians Organization, Boston, Massachusetts
| | - Keenae M Tiersma
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - McKinley Glover
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Massachusetts General Physicians Organization, Boston, Massachusetts
| | - Jo-Anne O Shepard
- Massachusetts General Physicians Organization, Boston, Massachusetts; Director, Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, Massacusetts
| | - Efren J Flores
- Harvard Medical School, Boston, Massachusetts; Officer, Radiology Community Health & Equity, Massachusetts General Hospital, Boston, Massacusetts.
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