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LCSR Facility Comparisons Report

TABLE OF CONTENTS

Report Overview

The interactive LCSR Facility Comparisons Report provides insight into a facility's performance on lung cancer screening quality measures and LungRADS compared to various peer groups. The report's performance improvement dashboards support facilities with quality improvement activities.


Report Access

Get started by signing in to the National Radiology Data Registry (NRDR) portal and selecting the LCSR under Quality Improvement Registries. From the LCSR main menu, under Interactive Reports, select the Facility Comparisons Report. The report is divided into nine dashboards displayed as tabs across the top of the screen. The About this Report dashboard provides a general overview of the information displayed across all dashboards.


Report Help Features 

The report is divided into nine tabs called dashboards located across the top. The About this Report dashboard provides a brief description of each dashboard, information about the measures and inclusion criteria, and a few pointers for navigating the dashboards. 

In each dashboard, hover the cursor over the information icon (blue circle) in the upper left corner to view a brief description of the dashboard's purpose and how to populate it with data. 


Once the report is populated with data, click the Help link to bring up an overlay with specific report navigation instructions. Click the Read about this report link to open this Knowledge Base article and the Feedback link to access the user input form.


LCSR Video Training Series


Note: The LCSR video training series includes four short videos covering the topics:

  • How to navigate the Facility Peer Comparisons Report

  • Investigate annual trend performance

  • How the LCSR performance measures are calculated

  • About Interpreting Peer Rankings


Report Dashboards

Facilities Map


The Facilities Map visually represents which facilities are included in the report's Census Division comparison statistics for a selected year. Each division is color coded. color-coded





Facility Peer Comparisons

The Facility Peer Comparisons Report tab compares a single site's data to various peer groups: 

  • in the same Census Division (e.g., East North Central, Mountain)

  • of the same facility type (e.g., Academic, Freestanding center)

  • in the same type of location (e.g., Suburban, Metropolitan), and

  • in the entire registry

The data table shows each measure, the measure rate, and the rate's numerator and denominator.


Note: Several new performance measures are now available in the report's Screened Population section:  

  • First-time screening  

  • Non-smoking Rate

  • Adherence to Annual Screening

  • Adherence to six-month interim screening

  • Adherence to three-month interim screening

The report's LCSR Measure Definitions tab briefly describes each measure, and more detailed information about each measure is also available here.



Each color-coded circle represents the site's quartile ranking compared to the peer group. For example, the highest 25% group typically indicates the facility performed well and was better than 75% of all sites in that group. The lower 25% suggests the facility performance was relatively poor, faring worse than 75% of all sites in the group.


Note: The Screened Population measure now includes results for the 2021 screening criteria recommended by the United States Preventative Services Task Force (USPSTF). The report will continue to show the USPSTF 2013 criteria for several years.


Additional details are available for each measure comparison by hovering over the circle. The above screenshot shows by hovering the mouse over the circle for the Adherence to Annual Screening measure, you can view details with the facility rate (dark blue dot) and each quartile (differently colored shaded areas) for all sites in the LCSR. 


Each shaded area represents the range of rates for one-quarter of LCSR facilities that met the 20-case threshold:

  • The leftmost shaded area shows 25% of sites had a rate of 5.8 or lower

  • The next shaded region is for sites that had a rate between 5.8 and 24.4

  • The third from the left shaded area is for sites with a rate between 24.4 and 42.5

  • The rightmost shaded region shows 25% of sites with rates greater than 42.5

Note: Some measures, such as volume CT dose index (CTDIvol) and dose length product (DLP), are inverse, so lower rates are better. For other rates, such as smoking cessation counseling, higher rates are better.


The Annual Trends Report tab provides rankings over time for the selected facility compared to all LCSR facilities that submit 20 or more cases per calendar year. Clicking on a measurement name in the table creates detailed graphs for that measure. The line chart compares the facility's rate (green line) to the registry median (gray line) for each available year. Therefore, for measures where higher rates are better, a facility rate below the registry median line means the facility performed worse than half of all sites in the LCSR. For inverse measures where higher rates are worse, the opposite is true – a facility rate above the registry median line means the facility performed worse than half of all sites in the LCSR.

Note: The registry median (gray line), also known as the 50th percentile, represents the midpoint across all facilities; that is, half of the facilities in the LCSR have a rate below this value, and half have a rate above this value.

 

Hover over a colored ranking circle or the registry data point (indicated by a dot with a numbered value) in the line chart to see details for that year, including the registry 25th, 50th (the median), 75th, and 95th percentiles. The bar chart shows the number of cases for the facility for the selected measure by year, providing context to the facility rate and ranking.


Facility Comparisons

The Facility Comparisons Report tab provides rankings for multiple facilities to compare data across facilities. The report also includes total measurement rates compiled across the selected facilities.


Hovering over a ranking circle provides additional information about the registry percentiles

determining the facility's ranking for that measure.

 

Lung-RADS Comparison

The Lung-RADS Comparison Report tab shows the percentage of lung cancer screening exams by Lung-RADS category for the year and facilities selected (light blue bars) and their total (green bar). Use the comparison filters (shaded in gray) to view Lung-RADS reporting results compared with the entire registry or facilities in a selected Census Division, Facility Category, or Location Type. Use the Statistic filter to choose a comparison percentile. The screenshot below shows the Lung-RADS reporting breakdown for two facilities compared with all academic facilities submitting data for 2021. The example shows the median percentile for reporting Lung-RADS 2 exam results among academic facilities in 2021 is 59.8%, demonstrating that the two facilities are well above the median for this Lung-RADS category.



Adherence to Annual Screening

The Adherence to Annual Screening Report tab provides insight into the percentage and number of patients who had a previous screening exam of LungRads 1 or 2 and returned for their annual screen. The report year is the date a patient returned for a screening exam if they returned within 15 months. You can view facility performance results by comparing categories of census division, facility type, location type, or the entire registry. You can also select a percentile for the comparison category that displays as a red line on the bar charts.


The blue bars in the first chart represent the percentage of patients who return for an annual screening exam within 11 to 15 months. The green bars show the total for all selected facilities. The example below displays the comparison data for three academic facilities with the red line showing the 50th percentile, or median, of all academic facilities submitting registry data. Hovering over the blue bar for a facility shows more specific details.  

Clicking a blue bar in the first chart enables you to drill into the adherence performance for a single facility. Clicking a blue bar in the second chart displays the individual cases for the facility for a specific period to track the percentage of patients who return for an annual screening exam within 16 to 24 months or greater than 24 months after their last annual exam. Patients who are overdue (have not returned within 11 to 15 months) for a follow-up exam are tracked in the No follow-up (overdue) column until they return.


Facility Characteristics

The Facility Characteristics tab displays the number of sites by Facility Type, Location Type, and Census Division. Each stacked bar chart denotes the number of sites that met the case threshold for the year (blue bars) and the number of sites that fell below the threshold (gray bars). 

LCSR Facility Characteristics

Performance Improvement

These reports are available to help facilities carry out an LCSR performance improvement (PI) activity. To learn how to use your LCSR data to improve program performance and patient care, see the article LCSR Performance Improvement Overview. Also, read the articles Increasing Adherence to Annual Screening - Data Review and Achieving Appropriate Radiation Dose - Data Review for details about how these reports can help you identify problem areas and demonstrate improvement. 


LCSR Measure Definitions

The last tab in the report provides definitions for all the report measures.


Date last reviewed: 02/09/23


Previous: Corporate Account Report

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