Introduction
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 improve the smoking cessation rate in your lung cancer screening patient population. 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 Screened Population.
Review the smoking cessation measures: smoking cessation counseling offered, smoking cessation counseling offered among current smokers, and non-smoking rate.
Facility performance compared with peers can be reviewed either across all sites in the LCSR (default view) or 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 lighter the blue circle, the more deviation the practice has from the peer group mean. The darker the circle, the better the performance. Use the circle’s color intensity to drill down into your data.
The example below shows the results for:
Comparison Year: 2021
Facility Type: Academic
Measure: Non-smoking rate
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 upper 25-50% quartile. This suggests the facility has an opportunity to increase the percentage of their patients who are not smoking which accounts for less than half (44.8%) of total patients.
Review 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 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.
Gap Analysis
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 note how your performance compares to the registry’s median performance for smoking cessation measures.
Smoking cessation counseling offered
Smoking cessation counseling offered among current smokers
Non-smoking rate
You can determine which quartile your facility is in using the Facility Peer Comparisons tab (see #2 above). 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.
Help Tool
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 non-smoking rates. 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 performance is slightly above the registry median (dotted red line). The overall performance value of 47.8% for April through October 2021 is 8 percentage points above the registry median for all of 2020.
For corporate accounts with multiple facilities, use the filters to drill down to facility-level data and interact with the facility “bubble” to learn which sites have the greatest impact on the overall smoking cessation rate. Hover over a facility bubble to view details about a facility's contribution toward the average rate of all facilities. In the example below, the facility represented in yellow presents the best opportunity for improvement with a non-smoking rate of 38.9% that is nearly 9 percentage points below the overall corporate account performance.
If your user profile allows you to view exam details in reports, you can select Yes in the Show Detail filter to obtain exam-level information.
PI Assessment Report
The PI Assessment tab's filters enable you to select the performance parameters of your PI project by facility 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 month or by week. The graph above shows baseline performance data by month for January 2021 through September 2021 and post intervention performance data for January 2022 through August 2022. In this example, the facility has improved their mean performance by nearly 9 percentage points—from a baseline mean of 38.2% to a post-intervention mean of 47.1%.
The control limits (upper and lower red lines) help you assess if the project results suggest a significant and sustainable improvement. To learn about how control limits can help you assess your post-intervention performance, view the video Statistical Process Control.
You can also select a summary chart that compares the overall mean and 95% confidence interval for the time periods you selected as shown below.
