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Increasing Adherence to Annual Screening - Data Review


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 increase adherance to annual screening for patients with a Lung-RADS® 1 or 2 recommendation enrolled in your lung cancer screening program. 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.

  1. Review the LCSR Facility Peer Comparisons Report to view aggregate data about how your facility (or how multiple facilities within the same Corporate Account) compares to peer groups and to all registry participants.

    1. View your facility’s rankings for the three Plan-Do-Study-Act (PDSA) measures to determine if there are measures for which your facility falls below peer performance suggesting an opportunity for improvement.

    2. Even if your facility ranks in the highest quartile, consider if there is still significant room for improvement.

  2. Review the LCSR Facility Comparisons Report (for Corporate Accounts with more than one facility) to compare performance across all facilities within a Corporate Account.

    1. Identify which facilities could most benefit from participating in a performance improvement initiative or how your facility compares with others in your corporate account.

  3. Review the Annual Trends tab to observe performance over time to understand variations and determine factors within your program that may have led to changes in performance.

  4. Review the Adherence to Annual Screening tab to view your performance regarding the percentage of patients who return for follow-up screening within 11 to 15 months after their previous Lung-RADS® 1 or 2 screening exam.  

  5. Review the two PI Reports to focus on the parameters for your PDSA cycle.

    1. Decide if an improvement effort will include one or multiple facilities.

    2. Determine an appropriate date range for a good representation of your data.

    3. Evaluate the data to see if there is an improvement trend or if some adjustment needs to be made to the intervention.

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.

Help ToolClick 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

Investigate performance data available in the PI Analysis tab:

  1. Enter a Corporate Account, facilities to include (if more than one Facility is in a Corporate Account) and a date range. These data elements do not carry over from the Facility Peer Comparison report.

  2. Select a measure using the Chart Measure filter to view performance trends of interest.

  3. Use the Show Data By filter to select whether to view the aggregated performance data by Corporate Account or Facility (if more than one Facility is in a Corporate Account).

  4. Use the Comparison Statistics filter to view your performance as compared to the performance of all registry facilities (from the previous year) indicated by the dotted red line for the median, 75%, or 95% performance results.

  5. Use the Show Detail filter to select a summary trend view or a view that also includes a table with the exams contributing to the trend chart. 

An example of the PI Analysis Report below shows the adherence rate for multiple Facilities within a Corporate Account. The “opportunity” bubbles show the screening volume difference between the facilities indicated by the bubble size. The graph trend line shows the facilities' performance is mostly above the median performance as compared with the entire registry.


Another report example below shows the trend line for a single facility and the exam table (select Exams in the Show Details filter to view) for data submitted from June through September 2022. The report calculates adherence as the percentage of patients who return for an annual screening exam within 15 months of the previous screening. 

Hover over a dot in the trend chart to display the performance summary for a specific month.  Click a data point in the trend chart to filter the exams table.

PI Assessment Report

Calculate pre- and post-PI metrics for your PDSA project using the PI Assessment tab. The report plots adherence over time along with displaying the upper and lower control limits defined as +/- three standard deviations from the mean.

  1. Use the Baseline date selector to display your project’s baseline period. After your intervention, use the Post Intervention date selector to monitor its effect on performance.  

  2. Use the Show filter to view performance results by month or by week. Select the Baseline vs. Post Intervention option to view a side-by-side comparison of your project’s results.

  3. View a control limits video to learn more about their use for understanding performance improvement.

Note: The Corporate Account and Facility filters operate independently of the rest of the report. Consequently, selections from other Facility Peer Comparison reports do not carry over to the performance improvement reports.

The PI Assessment tab below displays an example of three months of baseline data followed by a three-month timeframe for implementing an intervention. Three months post intervention, the data suggest modest improvement has been achieved and the facility should continue to monitor if the upward trend continues.

Selecting Baseline vs. Post Intervention in the Show filter displays the graph below demonstrating modest improvement.

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