Introduction
The project rationale describes a potential improvement opportunity for lung cancer screening (LCS) programs related to patients’ adherence to annual exams as documented in peer-reviewed literature and national guideline documents (see References below). This information is presented to provide facility personnel with an overview of the Lung Cancer Screening Registry (LCSR) measure and the impact on patient care.
The Adherence to Annual Screening measure can help facilities identify when and where patients are/are not returning for screening so that performance improvement activities can be initiated as needed.
This information is a first step in completing a performance improvement project using a PDSA model and is intended to provide a stepwise understanding about your patients’ adherence to annual LCS. The project is based on your data entered in the LCSR, including comparison to national data, and tailored to practices like yours.
Improving Adherence to Annual Screening Measure
The Adherence to Annual Screening measure is defined as the percentage of patients who returned within the annual screening window (11 to 15 months after their previous exam) when their previous exam met USPSTF screening appropriateness guidelines and was assigned a Lung-RADS® 1 or 2.
The adherence to annual screen percentage is calculated based on the number of patients who returned within the 11 to 15-month annual screen window divided by the number of patients who should have had an annual screen based on the Lung-RADS® 1 or 2 recommendation of the prior screening exam.
The data can also be viewed based on when and if the patient returned for a screening exam when the prior exam was given a Lung-RADS® 1 or 2. Time periods for return screening include <11 months, 11 to 15 months (adherent), 16 to 24 months, >24 months, or has not returned.
Project Rationale: Why is the Measure Important in Clinical Practice?
Improving annual LCS adherence allows identification of lung cancer at an earlier stage and improved outcomes. Screening high-risk patients with low-dose CT reduces deaths from lung cancer. The USPSTF recommends annual lung cancer screening for eligible patients which should continue until the patient no longer meets eligibility requirements [1]. In the NLST and NELSON trial, adherence to subsequent screening was high, >95% and >90% respectively. However, this was only for 3 annual screenings in the NLST and 4 annual screenings in the NELSON trial. The mortality benefit associated with LCS requires high adherence to follow-up recommendations. In fact, nearly 60% of the lung cancers in the NLST intervention group were detected after the 2nd and 3rd rounds of screening. One study has demonstrated a 7% rate of incident lung cancer developing within 6 years of receiving a negative baseline study. Outside of clinical trials, the adherence rate is much lower with a meta-analysis showing the overall adherence to LCS is 55% with rates varying from 12% to 91%.
There have been some factors which correlate with lower adherence rates. Current smokers, people of color, and those with lower education levels have lower adherence [2, 3]. Patients who have had no or overall less imaging outside of LCS were less likely to adhere to follow up recommendations [4].
A centralized program, which is generally one with a dedicated LCS team that facilitates returning for screening for patients, has demonstrated increased adherence. One study saw an increase in adherence from 22% to 66% after hiring a full-time LCS program coordinator [6]. Adherence has also been shown to be higher when an S-modifier is included in the Lung-RADS category.
References
USPSTF Lung cancer screening recommendation statement. Available at: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening. US Preventative Services Task Force. Updated March 2021. Accessed November 21, 2022.
Lopez-Olivo MA, Maki KG, Choi NJ, et al. Patient adherence to screening for lung cancer in the US: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(11):e2025102. doi: 10.1001/jamanetworkopen.2020.25102
Wildstein KA, Faustini Y, Yip R, Henschke CI, Ostroff JS. Longitudinal predictors of adherence to annual follow-up in a lung cancer screening programme. J Med Screen. 2011;18(3):154-9. doi: 10.1258/jms.2011.010127
Stowell JT, Narayan AK, Wang GX, et al. Factors affecting patient adherence to lung cancer screening: A multisite analysis. J Med Screen. 2021;28(3):357-364. doi: 10.1177/0969141320950783
Mazzone PJ, White CS, Kazerooni EA, Smith RA, Thomson CC. Proposed quality metrics for lung cancer screening programs: a National Lung Cancer Roundtable project. Chest. 2021;160(1):368-378. doi: 10.1016/j.chest.2021.01.063
Sakoda LC, Rivera MP, Zhang J, et al. Patterns and factors associated with adherence to lung cancer screening in diverse practice settings. JAMA Netw Open. 2021;4(4):e218559. doi: 10.1001/jamanetworkopen.2021.8559
Kazerooni EA, Austin JHM, Black WC, et al. ACR–STR practice parameter for the performance and reporting of lung cancer screening thoracic computed tomography (CT). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CT-LungCaScr.pdf. American College of Radiology. Updated 2019. Accessed November 21, 2022.