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Núñez ER, Ito Fukunaga M, Stevens GA, Yang JK, Reid SE, Spiegel JL, Ingemi MR, Wiener RS. Review of Interventions That Improve Uptake of Lung Cancer Screening: A Cataloging of Strategies That Have Been Shown to Work (or Not). Chest 2024:S0012-3692(24)00654-8. [PMID: 38797278 DOI: 10.1016/j.chest.2024.04.019] [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: 01/08/2024] [Revised: 04/08/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024] Open
Abstract
TOPIC IMPORTANCE Lung cancer screening (LCS) has the potential to decrease mortality from lung cancer by 20%. Yet, more than a decade since LCS was established as an evidence-based practice, < 20% of the eligible population in the United States has been screened. This review focuses on critically appraising interventions that have been designed to increase the initial uptake of LCS, including how they address known barriers to LCS and their effectiveness in overcoming these barriers. REVIEW FINDINGS Studies were categorized based on the primary barriers that they addressed: (1) identifying eligible patients (including enhancing awareness through smoking history collection, outreach, and education), (2) shared decision-making-related interventions, and (3) patient navigation interventions. Four of the studies included multicomponent interventions, which often included patient navigation as one of the components. Overall, the effectiveness of the studies reviewed at improving LCS uptake generally was modest and was limited by the multilevel barriers that need to be overcome. Multicomponent interventions generally were more effective at improving LCS uptake, but most studies still had relatively low completion of screening. SUMMARY Improving uptake of LCS requires learning from prior interventions to design multilevel interventions that address barriers to LCS at key steps and identifying which components of these interventions are effective and generalizable.
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Affiliation(s)
- Eduardo R Núñez
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | | | - Gregg A Stevens
- University of Massachusetts Chan Medical School Worcester, MA
| | - James K Yang
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Sarah E Reid
- University of Massachusetts Chan Medical School Worcester, MA
| | - Jennifer L Spiegel
- University of Massachusetts Chan Medical School Worcester, MA; School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Molly R Ingemi
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA; National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
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Bao T, Liu B, Li R, Li Z, Ji G, Wang Y, Yang H, Li W, Huang W, Huang Y, Tang H. LDCT screening results among eligible and ineligible screening candidates in preventive health check-ups population: a real world study in West China. Sci Rep 2024; 14:4848. [PMID: 38418532 PMCID: PMC10902338 DOI: 10.1038/s41598-024-55475-x] [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: 09/05/2023] [Accepted: 02/23/2024] [Indexed: 03/01/2024] Open
Abstract
To compare the LDCT screening results between eligible and ineligible screening candidates in preventive health check-ups population. Using a real-world LDCT screening results among people who took yearly health check-up in health management center of West China Hospital between 2006 and 2017. Objects were classified according to the China National Lung Cancer Screening Guideline with Low-dose Computed Tomography (2018 version) eligibility criteria. Descriptive analysis were performed between eligible and ineligible screening candidates. The proportion of ineligible screening candidates was 64.13% (10,259), and among them there were 4005 (39.04%) subjects with positive screenings, 80 cases had a surgical lung biopsy. Pathology results from lung biopsy revealed 154 cancers (true-positive) and 26 benign results (false-positive), the surgical false-positive biopsy rate was 4.17%, and ineligible group (7.69%) was higher than eligible group (2.47%), P < 0.05. Further, in ineligible screening candidates, the proportion of current smokers was higher among males compared to females (53.85% vs. 4.88%, P < 0.05). Of the 69 lung cancer patients detected in ineligible screening candidates, lung adenocarcinoma accounts for a high proportion of lung cancers both in male (75.00%) and female (85.00%). The proportion of ineligible screening candidates and the surgical false-positive biopsy rate in ineligible candidates were both high in health check-ups population.
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Affiliation(s)
- Ting Bao
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China
- Translational Informatics Center, Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610212, China
| | - Bingqing Liu
- West China School of Public Health, Department of Epidemiology and Health Statistics, Sichuan University, Chengdu, 610041, China
| | - Ruicen Li
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhenzhen Li
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Guiyi Ji
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Youjuan Wang
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hanwei Yang
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Weimin Li
- Department of Pulmonary and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, 610041, China
| | - Wenxia Huang
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Yan Huang
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Huairong Tang
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Poon C, Wilsdon T, Sarwar I, Roediger A, Yuan M. Why is the screening rate in lung cancer still low? A seven-country analysis of the factors affecting adoption. Front Public Health 2023; 11:1264342. [PMID: 38026274 PMCID: PMC10666168 DOI: 10.3389/fpubh.2023.1264342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Strong evidence of lung cancer screening's effectiveness in mortality reduction, as demonstrated in the National Lung Screening Trial (NLST) in the US and the Dutch-Belgian Randomized Lung Cancer Screening Trial (NELSON), has prompted countries to implement formal lung cancer screening programs. However, adoption rates remain largely low. This study aims to understand how lung cancer screening programs are currently performing. It also identifies the barriers and enablers contributing to adoption of lung cancer screening across 10 case study countries: Canada, China, Croatia, Japan, Poland, South Korea and the United States. Adoption rates vary significantly across studied countries. We find five main factors impacting adoption: (1) political prioritization of lung cancer (2) financial incentives/cost sharing and hidden ancillary costs (3) infrastructure to support provision of screening services (4) awareness around lung cancer screening and risk factors and (5) cultural views and stigma around lung cancer. Although these factors have application across the countries, the weighting of each factor on driving or hindering adoption varies by country. The five areas set out by this research should be factored into policy making and implementation to maximize effectiveness and outreach of lung cancer screening programs.
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Affiliation(s)
| | - Tim Wilsdon
- Charles River Associates, London, United Kingdom
| | - Iqra Sarwar
- Charles River Associates, London, United Kingdom
| | | | - Megan Yuan
- Merck & Co., Inc., Kenilworth, NJ, United States
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Wain K, Carroll NM, Honda S, Oshiro C, Ritzwoller DP. Individuals Eligible for Lung Cancer Screening Less Likely to Receive Screening When Enrolled in Health Plans With Deductibles. Med Care 2023; 61:665-673. [PMID: 37582296 PMCID: PMC10840830 DOI: 10.1097/mlr.0000000000001903] [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] [Indexed: 08/17/2023]
Abstract
BACKGROUND In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement. METHODS This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans. RESULTS The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities. CONCLUSIONS These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS.
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Affiliation(s)
- Kris Wain
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Nikki M. Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Stacey Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI
- Hawaii Permanente Medical Group, Honolulu, HI
| | - Caryn Oshiro
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI
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Núñez ER, Lindenauer PK, Wiener RS. Electronic Health Record-Based Algorithms as Part of the Solution for Improving Lung Cancer Screening. JCO Clin Cancer Inform 2023; 7:e2300222. [PMID: 38055916 DOI: 10.1200/cci.23.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/06/2023] [Indexed: 12/08/2023] Open
Abstract
New EHR-based algorithm in #ClinicalCancerInformatics offers a glimpse into the future of lung cancer screening eligibility prediction. Great promise, yet hurdles in implementation and comprehensive strategies for screening are needed for a substantial impact.
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Affiliation(s)
- Eduardo R Núñez
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Peter K Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA
- VA Bedford Healthcare System, Bedford, MA
- The Pulmonary Center, Boston University School of Medicine, Boston, MA
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
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Burnett-Hartman AN, Powers JD, Hixon BP, Carroll NM, Frankland TB, Honda SA, Saia C, Rendle KA, Greenlee RT, Neslund-Dudas C, Zheng Y, Vachani A, Ritzwoller DP. Development of an Electronic Health Record-Based Algorithm for Predicting Lung Cancer Screening Eligibility in the Population-Based Research to Optimize the Screening Process Lung Research Consortium. JCO Clin Cancer Inform 2023; 7:e2300063. [PMID: 37910824 PMCID: PMC10642899 DOI: 10.1200/cci.23.00063] [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: 04/12/2023] [Revised: 07/21/2023] [Accepted: 09/14/2023] [Indexed: 11/03/2023] Open
Abstract
PURPOSE Lung cancer screening (LCS) guidelines in the United States recommend LCS for those age 50-80 years with at least 20 pack-years smoking history who currently smoke or quit within the last 15 years. We tested the performance of simple smoking-related criteria derived from electronic health record (EHR) data and developed and tested the performance of a multivariable model in predicting LCS eligibility. METHODS Analyses were completed within the Population-based Research to Optimize the Screening Process Lung Consortium (PROSPR-Lung). In our primary validity analyses, the reference standard LCS eligibility was based on self-reported smoking data collected via survey. Within one PROSPR-Lung health system, we used a training data set and penalized multivariable logistic regression using the Least Absolute Shrinkage and Selection Operator to select EHR-based variables into the prediction model including demographics, smoking history, diagnoses, and prescription medications. A separate test data set assessed model performance. We also conducted external validation analysis in a separate health system and reported AUC, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy metrics associated with the Youden Index. RESULTS There were 14,214 individuals with survey data to assess LCS eligibility in primary analyses. The overall performance for assigning LCS eligibility status as measured by the AUC values at the two health systems was 0.940 and 0.938. At the Youden Index cutoff value, performance metrics were as follows: accuracy, 0.855 and 0.895; sensitivity, 0.886 and 0.920; specificity, 0.896 and 0.850; PPV, 0.357 and 0.444; and NPV, 0.988 and 0.992. CONCLUSION Our results suggest that health systems can use an EHR-derived multivariable prediction model to aid in the identification of those who may be eligible for LCS.
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Affiliation(s)
| | - J. David Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Brian P. Hixon
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Nikki M. Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | | | - Stacey A. Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Oahu, HI
- Hawaii Permanente Medical Group, Oahu, HI
| | - Chelsea Saia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Yingye Zheng
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA
| | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Rendle KA, Steltz JP, Cohen S, Schapira MM, Wender RC, Bekelman JE, Vachani A. Estimating Pack-Year Eligibility for Lung Cancer Screening Using 2 Yes or No Questions. JAMA Netw Open 2023; 6:e2327363. [PMID: 37548980 PMCID: PMC10407683 DOI: 10.1001/jamanetworkopen.2023.27363] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023] Open
Abstract
This cross-sectional study describes the development and testing the accuracy of using 2 yes or no questions to estimate pack-year eligibility for lung cancer screening.
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Affiliation(s)
- Katharine A. Rendle
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Jennifer P. Steltz
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania
- Division of Pulmonary and Critical Care, University of Pennsylvania School of Medicine, Philadelphia
| | - Sarah Cohen
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Marilyn M. Schapira
- Department of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Richard C. Wender
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Justin E. Bekelman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anil Vachani
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania
- Division of Pulmonary and Critical Care, University of Pennsylvania School of Medicine, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Gundle K, Hooker ER, Golden SE, Shull S, Crothers K, Melzer AC, Slatore CG. Use of Veterans Health Administration Structured Data to Identify Patients Eligible for Lung Cancer Screening. Mil Med 2023; 188:e2419-e2423. [PMID: 36722178 DOI: 10.1093/milmed/usad017] [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: 11/02/2022] [Revised: 12/29/2022] [Accepted: 01/17/2023] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Lung cancer screening (LCS) uptake is low. Assessing patients' cigarette pack-years and years since quitting is challenging given the lack of documentation in structured electronic health record data. MATERIALS AND METHODS We used a convenience sample of patients with a chest CT scan in the Veterans Health Administration. We abstracted data on cigarette use from electronic health record notes to determine LCS eligibility based on the 2021 U.S. Preventive Services Task Force age and cigarette use eligibility criteria. We used these data as the "ground truth" of LCS eligibility to compare them with structured data regarding tobacco use and a COPD diagnosis. We calculated sensitivity and specificity as well as fast-and-frugal decision trees. RESULTS For 50-80-year-old veterans identified as former or current tobacco users, we obtained 94% sensitivity and 47% specificity. For 50-80-year-old veterans identified as current tobacco users, we obtained 59% sensitivity and 79% specificity. Our fast-and-frugal decision tree that included a COPD diagnosis had a sensitivity of 69% and a specificity of 60%. CONCLUSION These results can help health care systems make their LCS outreach efforts more efficient and give administrators and researchers a simple method to estimate their number of possibly eligible patients.
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Affiliation(s)
- Kenneth Gundle
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, Portland, OR 97239, USA
| | - Elizabeth R Hooker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR 97239, USA
| | - Sara E Golden
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR 97239, USA
| | - Sarah Shull
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR 97239, USA
| | - Kristina Crothers
- Division of Pulmonary, Critical Care & Medicine, VA Puget Sound Health Care System and Department of Medicine, University of Washington, Seattle, WA 98108, USA
| | - Anne C Melzer
- Section of Pulmonary & Critical Care Medicine, VA Minneapolis Health Care System, Minneapolis, MN, USA
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR 97239, USA
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
- Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System, Portland, OR 97239, USA
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Kunitomo Y, Bade B, Gunderson CG, Akgün KM, Brackett A, Tanoue L, Bastian LA. Evidence of Racial Disparities in the Lung Cancer Screening Process: a Systematic Review and Meta-Analysis. J Gen Intern Med 2022; 37:3731-3738. [PMID: 35838866 PMCID: PMC9585128 DOI: 10.1007/s11606-022-07613-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Annual lung cancer screening (LCS) with low-dose chest computed tomography for high-risk individuals reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality exist, less is known about disparities in LCS participation. We conducted a systematic review to explore LCS participation in Black compared with White patients in the USA. 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 LCS participation and compared rates by race. Studies were pooled using random-effects meta-analysis. RESULTS We screened 18,300 titles/abstracts; 229 studies were selected for full-text review, of which nine studies met inclusion criteria. Studies were categorized into 2 groups: studies that reported the screening rate among an LCS-eligible patient population, and studies that reported the screening rate among a patient population referred for LCS. Median LCS participation rates were 14.4% (range 1.7 to 62.6%) for eligible patient studies and 68.5% (range 62.6 to 88.8%) for referred patient studies. The meta-analyses showed screening rates were lower in the Black compared to White population among the LCS-eligible patient studies ([OR]=0.43, [95% CI: 0.25, 0.74]). However, screening rates were the same between Black and White patients in the referred patient studies (OR=0.94, [95% CI: 0.74, 1.19]). DISCUSSION Black LCS-eligible patients are being screened at a lower rate than White patients but have similar rates of participation once referred. Differences in referrals by providers may contribute to the racial disparity in LCS participation. More studies are needed to identify barriers to LCS referral and develop interventions to increase provider awareness of the importance of LCS in Black patients. Trial Registry PROSPERO; No.: CRD42020214213; URL: http://www.crd.york.ac.uk/PROSPERO.
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Affiliation(s)
- Yukiko Kunitomo
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Brett Bade
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Craig G Gunderson
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Kathleen M Akgün
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale University School of Medicine, New Haven, CT, USA
| | - Lynn Tanoue
- Yale University School of Medicine, New Haven, CT, USA
| | - Lori A Bastian
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA.
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA.
- Yale University School of Medicine, New Haven, CT, USA.
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Maurice NM, Tanner NT. Lung cancer screening at the VA: Past, present and future. Semin Oncol 2022; 49:S0093-7754(22)00041-0. [PMID: 35831214 DOI: 10.1053/j.seminoncol.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/04/2022] [Indexed: 11/11/2022]
Abstract
Lung cancer is responsible for more deaths annually in the United States than breast, prostate and colon cancers combined. Lung cancer screening with annual low-dose computed tomography reduces lung cancer mortality in high-risk patients through early detection. The incidence of lung cancer is higher in the veteran population compared to the general population due, in part, to the prevalence of tobacco use. Early detection of lung cancer is therefore an important goal of the Veterans Health Administration (VHA), the largest integrated health care system in the United States. The following will review previous and current initiatives undertaken by the VHA to implement and expand access to lung cancer screening and will highlight target areas of interest to improve uptake and quality of lung cancer screening. Through these initiatives and programs, the VHA aims to provide high quality and equitable access to lung cancer screening for all Veterans that incorporates research that will improve outcomes and potentially inform and optimize the practice of Lung cancer screening across the United States.
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Affiliation(s)
- Nicholas M Maurice
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA, U.S.A.; Atlanta Veterans Affairs Health Care System, Decatur, GA.
| | - Nichole T Tanner
- Ralph H. Johnson Veterans Affairs Hospital, Health Equity and Rural Outreach Innovation Center (HEROIC), Charleston, SC, U.S.A.; Medical University of South Carolina, Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Charleston, SC, U.S.A
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Rustagi AS, Byers AL, Keyhani S. Likelihood of Lung Cancer Screening by Poor Health Status and Race and Ethnicity in US Adults, 2017 to 2020. JAMA Netw Open 2022; 5:e225318. [PMID: 35357450 PMCID: PMC8972038 DOI: 10.1001/jamanetworkopen.2022.5318] [Citation(s) in RCA: 28] [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) via low-dose chest computed tomography can prevent mortality through surgical resection of early-stage cancers, but it is unknown whether poor health is associated with screening. Though LCS may be associated with better outcomes for non-Hispanic Black individuals, it is unknown whether racial or ethnic disparities exist in LCS use. OBJECTIVE To determine whether health status is associated with LCS and whether racial or ethnic disparities are associated with LCS independently of health status. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, population-based study of community-dwelling US adults used data from Behavioral Risk Factor Surveillance System annual surveys, 2017 to 2020. Participants were aged 55 to 79 years, with a less than 30 pack-year smoking history, and were current smokers or those who quit within 15 years. Data were analyzed from August to November 2021. EXPOSURES Self-reported health status and race and ethnicity. MAIN OUTCOMES AND MEASURES Self-reported LCS in the last 12 months. RESULTS Of 14 550 individuals (7802 men [55.5%]; 7527 [55.0%] aged 65-79 years [percentages are weighted]), representing 3.68 million US residents, 17.0% (95% CI, 15.1%-18.9%) reported undergoing LCS. The prevalence of LCS was lower among non-Hispanic Black than non-Hispanic White individuals but not to a significant degree (12.0% [95% CI, 4.3%-19.7%] vs 17.5% [95% CI, 15.6%-19.5%]; P = .57). Health status was associated with LCS: 468 individuals in poor health vs 96 individuals in excellent health reported LCS (25.2% [95% CI, 20.6%-29.9%] vs 7.6% [95% CI, 5.0%-10.3%]; P < .001), and those with difficulty climbing stairs were more likely to report LCS than those without this functional limitation. Adjusting for sociodemographic factors, functional status, and comorbidities, self-rated health status remained associated with LCS (adjusted odds ratio, 1.19 per each 1-step decline in health; 95% CI, 1.03-1.38), and non-Hispanic Black individuals were 53% less likely to report LCS than non-Hispanic White individuals (adjusted odds ratio, 0.47; 95% CI, 0.24-0.90). Results were robust in sensitivity analyses in which health was alternatively quantified as number of comorbidities. CONCLUSIONS AND RELEVANCE LCS in the US is more common among those who may be less likely to benefit from screening because of poor underlying health. Furthermore, racial or ethnic disparities were evident after accounting for health status, with non-Hispanic Black individuals nearly half as likely as non-Hispanic White individuals to report LCS despite the potential for greater benefit of screening this population.
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Affiliation(s)
- Alison S. Rustagi
- Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco
| | - Amy L. Byers
- Department of Medicine, University of California, San Francisco
- Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Weill Institute for Neurosciences, University of California, San Francisco
| | - Salomeh Keyhani
- Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco
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Maki KG, Shete S, Volk RJ. Examining lung cancer screening utilization with public-use data: Opportunities and challenges. Prev Med 2021; 147:106503. [PMID: 33675881 DOI: 10.1016/j.ypmed.2021.106503] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 11/29/2022]
Abstract
Lung cancer screening with low-dose computed tomography is recommended for high-risk smokers who meet specific eligibility criteria. Current guidelines suggest that eligible adults with a heavy smoking history will benefit from annual low dose computed tomography but due to several associated risks (e.g., false-positives, radiation exposure, overdiagnosis) a shared decision-making consultation is required by the Centers for Medicare & Medicaid Services, and endorsed by the United States Preventive Services Task Force. In order to examine potential for tracking LCS uptake, adherence, and patient-provider communication at a national level, we reviewed four regularly publicly available national surveys (National Health Interview Survey [NHIS], Behavioral Risk Factor Surveillance System [BRFSS], National Health and Nutrition Examination Survey [NHANES], and Health Information National Trends Survey [HINTS]) to assess available data; an overview of 37 publications using these sources is also provided. The results show that none of the surveys include items that fully assess current LCS guidelines. Implications for future research-including the potential to examine factors associated with LCS uptake and patient-provider communication-are addressed.
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Affiliation(s)
- Kristin G Maki
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1444, Houston, TX 77030, USA.
| | - Sanjay Shete
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1411, Houston, TX 77030, USA; Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1411, Houston, TX 77030, USA.
| | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1444, Houston, TX 77030, USA.
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Boudreau JH, Miller DR, Qian S, Nunez ER, Caverly TJ, Wiener RS. Access to Lung Cancer Screening in the Veterans Health Administration: Does Geographic Distribution Match Need in the Population? Chest 2021; 160:358-367. [PMID: 33617804 DOI: 10.1016/j.chest.2021.02.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Studies show uneven access to Medicare-approved lung cancer screening (LCS) programs across the United States. The Veterans Health Administration (VA), the largest national US integrated health system, is potentially well positioned to coordinate LCS services across regional units to ensure that access matches distribution of need nationally. RESEARCH QUESTION To what extent does LCS access (considering both VA and partner sites) and use match the distribution of eligible Veterans at state and regional levels? METHODS In this retrospective analysis, we identified LCS examinations in VA facilities between 2013 and 2019 from the VA Corporate Data Warehouse and plotted VA facilities with LCS geographically. We compared estimated LCS rates (unique Veterans screened per LCS-eligible population) across states and VA regional units. Finally, we assessed whether the VA's new partnership with the GO2 Foundation for Lung Cancer (which includes more than 750 LCS centers) closes geographic gaps in LCS access. RESULTS We identified 71,898 LCS examinations in 96 of 139 (69.1%) VA facilities in 44 states between 2013 and 2019, with substantial variation across states (0-8 VA LCS facilities per state). Screening rates among eligible Veterans in the population varied more than 30-fold across regional networks (rate ratio, 33.6; 95% CI, 30.8-36.7 for VA New England vs Veterans Integrated Service Network 4), with weak correlation between eligible populations and LCS rates (coefficient, -0.30). Partnering with the GO2 Foundation for Lung Cancer expands capacity and access (eg, all states now have ≥ 1 VA or partner LCS site), but 9 of the 12 states with the highest proportions of rural Veterans still have ≤ 3 total LCS facilities. INTERPRETATION Disparities in LCS access exist based on where Veterans live, particularly for rural Veterans, even after partnering with the GO2 Foundation for Lung Cancer. The nationally integrated VA system has an opportunity to leverage regional resources to distribute and coordinate LCS services better to ensure equitable access.
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Affiliation(s)
- Jacqueline H Boudreau
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA; Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, MA
| | - Shirley Qian
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA
| | - Eduardo R Nunez
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA; The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Tanner J Caverly
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Learning Health Sciences and Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA; The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA.
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Melzer AC, Golden SE, Ono SS, Datta S, Triplette M, Slatore CG. "We Just Never Have Enough Time": Clinician Views of Lung Cancer Screening Processes and Implementation. Ann Am Thorac Soc 2020; 17:1264-1272. [PMID: 32497437 DOI: 10.1513/annalsats.202003-262oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/04/2020] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Despite a known mortality benefit, lung cancer screening (LCS) implementation has been unexpectedly slow. New programs face barriers to implementation, which may include lack of clinician engagement or beliefs that the intervention is not beneficial. OBJECTIVE To evaluate diverse clinician perspectives on their views of LCS and their experience with LCS implementation and processes. METHODS We performed a qualitative study of clinicians participating in LCS. Clinicians were drawn from three medical centers, representing diverse specialties and practice settings. All participants practiced at sites with formal lung cancer screening programs. We performed semi-structured interviews with probes designed to elicit opinions of LCS, perceived evidence gaps, and recommendations for improvements. Transcribed interviews were iteratively reviewed and coded using directed content analysis. RESULTS Participants (n=24) included LCS coordinators, pulmonologists, physician and non-physician primary care providers (PCPs), a surgeon, and a radiologist. Most clinicians expressed that the evidence supporting LCS was adequate to support clinical adoption, though most PCPs had little direct knowledge and based decisions on local recommendations or endorsement by the US Preventative Services Task Force (USPSTF). Many PCPs endorsed lack of knowledge of eligibility requirements and screening strategy (e.g. annual while eligible). Clinicians with more lung cancer screening knowledge, including several PCPs, identified a number of gaps in the current evidence that tempered enthusiasm, including: unclear ideal screening interval, populations with high cancer risk that do not qualify under USPSTF, indications to stop screening, and the role of serious comorbidities. Support for centralized programs and LCS coordinators was strong, but not uniform. Clinicians were frustrated by time limitations during a patient encounter, costs to the patient, and issues with insurance coverage. Many gaps in informatics support were identified. Clinicians recommended working to improve informatics support, continuing to clarify clinician responsibilities, and working on increasing public awareness of LCS. CONCLUSIONS Despite working within programs that have adopted many recommended care processes to support LCS, clinicians identified a number of issues in providing high-quality LCS. Many of these issues are best addressed by improved support of LCS within the electronic health record and continued education of staff and patients.
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Affiliation(s)
- Anne C Melzer
- University of Minnesota, 5635, Division of Pulmonary, Allergy, Critical Care and Sleep, Minneapolis, Minnesota, United States
- Minneapolis VA Healthcare System, Center for Care Delivery and Outcomes Research, Minneapolis, Minnesota, United States;
| | - Sara E Golden
- Portland VA Medical Center, 20088, Center to Improve Veteran Involvement in Care, Portland, Oregon, United States
| | - Sarah S Ono
- Portland VA Medical Center, 20088, Center to Improve Veteran Involvement in Care, Portland, Oregon, United States
| | - Santanu Datta
- Duke University School of Medicine, 12277, Division of General Internal Medicine, Durham, North Carolina, United States
| | - Matthew Triplette
- Fred Hutchinson Cancer Research Center, 7286, Clinical Research Division, Seattle, Washington, United States
- University of Washington, 7284, Division of Pulmonary, Allergy, Critical Care and Sleep, Seattle, Washington, United States
| | - Christopher G Slatore
- VA Portland Health Care System, Section of Pulmonary and Critical Care Medicine, Portland, Oregon, United States
- Oregon Health & Science University, Division of Pulmonary and Critical Care Medicine, Portland, Oregon, United States
- Portland VA Medical Center, 20088, Center to Improve Veteran Involvement in Care, Portland, Oregon, United States
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