Introduction
The ACR's LCSR Committee established a subcommittee to focus on offering registry participants PI and educational opportunities. The subcommittee developed the PDSA Worksheet tailored for the LCSR PI projects and these accompanying instructional articles as tools for implementing and documenting PI efforts based on the Adherence to Annual Screening measure.
Below is a list of potential interventions to help improve adherence to annual lung cancer screening. This activity corresponds to the Plan section of the PDSA Worksheet. Interventions are suggested for addressing factors leading to performance gaps and demonstrating improved performance that you will record in the Do section of the PDSA Worksheet.
This is an area with limited scientific research and publications on the effectiveness of the proposed interventions. If there are supporting articles for a proposed intervention, they have been included for reference. However, many of the proposed interventions are based on the expert opinion of the subcommittee.
Consider using some of the tools for characterizing performance factors in the Set a Goal and Analyze Baseline Data section of the Performance Improvement Resources article.
Increase program factors effecting adherence such as:
Staff training (navigators, coordinators, technologists, persons doing shared decision making, and referring physicians) to educate patients about the importance of annual screens.
Screening center accessibility (ease of scheduling including hours of operation and appointment availability). Consider offering screening for a limited number of hours on the weekend, such as participating in Lung Cancer Screening Day.
Wernli KJ, Tuzzio L, Brush S, et al. Understanding Patient and Clinical Stakeholder Perspectives to Improve Adherence to Lung Cancer Screening. Perm J. 2021;25:20.295. doi: 10.7812/TPP/20.295
Intervention planning relevance: This publication describes how the Lung Cancer Screening (LCS) Program at Kaiser Permanente Washington (KPWA) identified clear gaps in adherence to LCS, organizational and clinical barriers to care, and potential design features for intervention to improve lung cancer screening in US settings.
Develop community outreach programs for patient populations with known lower adherence and culturally sensitive shared decision-making aids to include educational materials in other languages and at the appropriate literacy levels.
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
Intervention planning relevance: This publication examines LCS adherence rates in the US, finding that patient characteristics associated with lower adherence include current smoker, person of color, younger than 65 years, and less than a college education.
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 (Member login required)
Intervention planning relevance: This publication identifies factors associated with delayed adherence to follow-up in LCS, e.g., gender, age, and Lung-RADS® assessment, finding adherence to follow-up was higher among patients receiving more suspicious Lung-RADS® results at baseline screening CT and among those who had undergone imaging examinations outside of LCS prior to baseline lung cancer screening CT.
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
Intervention planning relevance: This publication examined rates and factors associated with adherence to annual repeat LCS in two cohorts: self-pay ($300.00) and no-pay, finding lower adherence among self-pay. Both cohorts showed higher adherence rates among Caucasians and those who had a college degree.
Improve/expand process for reminder communications with patients and referring providers regarding the need for annual screening, such as:
Use a dedicated database and screening navigation to track patient appointments.
Schedule an annual follow-up appointment as soon as the window of pre-authorization opens.
Send a courtesy reminder letter to patient and provider 30 days in advance of the recommended follow-up testing.
Send reminder letters 30, 60, and 90 days after screening due date to patients and providers.
Conduct outreach calls to referring provider offices if screening is overdue and track completion of follow-up exams.
Fill in a postcard with patient’s name, address, and date of screening, and file by month. Once a month, send out the next annual prefilled reminder postcards from the file.
Percac-Lima S, Ashburner JM, Rigotti NA, et al. Patient navigation for lung cancer screening among current smokers in community health centers a randomized controlled trial. Cancer Med. 2018;7(3):894-902. doi: 10.1002/cam4.1297
Intervention planning relevance: This publication describes the process for forming an LCS patient navigation (PN) program and team of lay navigators in community health centers and the interventions taken to ensure patients came in for scheduled screening. In addition to navigators helping patients overcome obstacles to get screened, navigators collaborated with PCPs regarding patient eligibility and follow up. The PN program appeared efficacious in all patient subgroups examined, but further studies are needed.
After the Screening Study— Surveillance and Follow-up. American Thoracic Society and American Lung Association. Available at: https://www.lungcancerscreeningguide.org/program-navigation-and-data-tracking/after-the-screening-study. Lung Cancer Screening Implementation Guide. Accessed November 21, 2022.
Intervention planning relevance: This resource provides a template for a courtesy reminder letter to patient and provider 30 days prior to the screening CT anniversary date (under Recommendations for tracking annual exams and assessing adherence).
Decrease barriers to ordering annual screening exams for referring providers. Send order for future activation to the provider 30 days before the annual date. The provider can accept the order or decline the order if the patient is not eligible anymore.
After the Screening Study— Surveillance and Follow-up. American Thoracic Society and American Lung Association. Available at: https://www.lungcancerscreeningguide.org/program-navigation-and-data-tracking/after-the-screening-study. Lung Cancer Screening Implementation Guide. Accessed November 21, 2022.
Intervention planning relevance: This resource provides recommendations for tracking annual exams and assessing adherence.
Establish more targeted outreach to patients who have not had prior imaging other than a low-dose CT screening as a participant in a lung cancer screening program.
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 (Member login required)
Intervention planning relevance: This publication identifies factors associated with delayed adherence to follow-up in LCS, e.g., gender, age, and Lung-RADS® assessment, finding adherence to follow-up was higher among patients receiving more suspicious Lung-RADS® results at baseline screening CT and among those who had undergone imaging examinations outside of LCS prior to baseline lung cancer screening CT.
Build a centralized LCS program. Centralized programs generally have a dedicated team that includes clinicians and coordinators and the infrastructure to manage and support the screening program, including tracking and notifying individuals they are due for screening and helping facilitate the screening process for the patient.
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