This article provides a step-by-step review of the Lung Cancer Screening Registry (LCSR) reports you can use to determine if your facility can bring radiation dose administered to patients enrolled in your lung cancer screening program closer to evidence-based guidelines. If a gap in performance is identified, pursuing a LCSR Plan-Do-Study-Act (PDSA) Performance Improvement project could help your facility get on the road to improvement. Visit LCSR Performance Improvement Overview for details about conducting a project.
Reviewing the Reports
Get started by reading the LCSR Facility Comparisons Report article available in the NRDR Support’s Knowledge Base for information about how to access the report and an overview of the various report tabs. Each report tab contains help features that provide more information about the report’s functionality. The report is viewable by all NRDR user profiles with the exception of Service User.
Note: Please keep in mind your facility’s data submission practices when reviewing the reports and how these may affect report results.
The following is a suggested stepwise progression for reviewing the LCSR Facility Comparisons Report tabs to help pinpoint areas that could benefit from a performance improvement initiative.
Open the LCSR Facility Comparisons Report and select the Facility Peer Comparisons tab. Populate each of the drop-down filters, clicking Apply at the bottom of each drop-down tab.
Year: Select the year(s) of interest for which you would like to review your data.
Corporate Account: Prepopulated unless your organization has more than one corporate account.
Facility: Select your facilities if your corporate account has more than one facility.
Report Section: Select During the Exam.
Review the CTDIvol measures.
Note that radiation dose is an inverse measure, meaning that lower radiation exposure and performance in the lowest quartile that gives optimum quality images is generally preferred.
Facility performance compared with peers can be reviewed either across all sites in the LCSR and by census division, facility type, or geographic location, as applicable to your practice.
Hover over a blue circle to see the details for the measure, including the facility rate and detailed comparison to the peer group. The horizontal bar shows each of the quartiles colored from lowest to highest along with the facility rate.
The darker the blue circle, the more deviation the practice has from the peer group mean. The lighter the circle the better performance. Use the circle’s color intensity to drill down into your data.
The example below shows the results for:
Comparison Year: 2021
Division: East North Central
Measure: CTDIvol for a healthy-weight patient
The facility measure rates are sorted into four quartiles of highest to lowest. The blue circle represents the facility’s rate which falls into the highest quartile suggesting the facility may want to take action to reduce the radiation dose for healthy-weight patients.
Select the Annual Trends tab to monitor facility performance over time compared with the entire registry, and to observe if improvements have been made and are being sustained.
Select a CTDIvol measure to display a chart with a line graph that compares your facilities' rate with all the facilities in the registry.
Select the Facility Comparisons tab (for corporate accounts with more than one facility) to view the performance of all facilities within the same corporate account.
This may help to identify facilities across a health system or network that are performing better or worse than other facilities within the same system for targeted quality improvement.
Radiation exposure for lung cancer screening CT is reported to the registry nearly 100% of the time and is robust. Now that you know how to view your data, it is important to look for opportunities to improve your performance.
First, look at your data and decide if the radiation dose is within the specified range in the ACR Practice Parameter described below across all of the Body Mass Index (BMI) categories:
CTDIvol <3.0 mGy for a standard-sized patient, with adjustments made for smaller and larger patients. By definition, a standard-sized patient is approximately 5'7" and 155 pounds or 170 cm and 70 kg, with a BMI ≈ 24.
Note also how your performance compares to the registry’s median performance. If you determine there is an opportunity for improvement, the next step is to begin the PDSA Performance Improvement project using the reports described below.
Performance Improvement (PI) Reports
Two report tabs are available in the LCSR Facility Comparisons report to help you dig deeper into your performance data, establish timelines for your PDSA PI project, and monitor improvement over time to determine if improvements are sustained.
Click the Help link in the upper left corner to produce a report overlay that provides detailed information about the report’s functionality.
PI Analysis Report
The PI Analysis tab provides several views to help you identify issues causing suboptimal radiation dose. Upon opening the report, view trend data at the corporate account level. The varying thickness of the trend line denotes changes in volume. Hover over a dot in the trend line to view the details. In the example below, the corporate account results are below the registry median (dotted red line).
For corporate accounts with multiple facilities, use the filters to drill down to facility-level data and interact with the facility “bubble” to highlight sites with the greatest impact on the overall radiation dose index. Hover over a facility bubble to view details about a facility's contribution toward the average dose of all facilities. In the example below, the trend line for Facility 1 shows CTDIvol above the registry median.
Select Yes in the Show Details filter to display a table of exams and a graph of exams by BMI category for a specific time period. Hover over a bubble in the BMI graph to show the details such as the category, number of exams, and average mGy/exam. Select a point in the trend graph or a bubble in the BMI category graph to filter the exam table. To remove the filter, click the dot or bubble again. Dose information is color coded: lowest doses are dark blue, highest doses are dark red, and the middle doses are grey.
PI Assessment Report
The PI Assessment tab's filters enable you to select the performance parameters of your PI project by facility, BMI category, and timeframe. Enter a baseline date range that reflects your performance status prior to implementing an intervention. After completing your intervention and waiting a reasonable time for the intervention’s effect on performance to occur, enter your post-intervention date range to see if the intervention met your performance target.
Use the Show filter to select a view of performance by week (as shown in the graph above) or by month.
The control limits (upper and lower red lines) help you assess if the project results suggest a significant and sustainable improvement. To learn more about how control limits can help you assess your post-intervention performance, view the video Statistical Process Control.