Overview

This program at an urban community hospital utilized a new lung cancer screening pathway to improve personalized preventive care. 

Organization Name

Valley Medical Center

Organization Type

• Academic Medical Center
• Community hospital

National/Policy Context

• In both men and women, lung cancer is the leading cause of cancer-related mortality (American Cancer Society 2014).
• According to the USPSTF (U.S. Preventive Services Task Force), annual lung cancer screenings and low dose computed tomography (CT) scans are recommended for asymptomatic patients at high risk due to age and smoking history (U.S. Preventive Services Task Force 2013).

Tools or Products Developed

 

• Modifications to EHR (Electronic Health Record)/Epic:
  • A quality alert was added as a point-of-care decision, alerting care providers of patients eligible for lung cancer screening.
  • A smartset then allows providers to order a lung CT and complete the shared decision-making process with just one click.
  • 

Training

• Care providers were trained in the following skills:
  • Recognizing criteria for screening (see Patient section)
  • Risk stratification (discuss potential benefits/harms of undergoing screening and patient willingness to undergo invasive diagnostic processes)
  • Follow up protocol (to ensure the screening takes place and obtain the results) 
  • Shared decision-making (integrating with imaging and pulmonology departments)
  • Patient education (informing the patient of the screening results)

Tech Involved

• Electronic medical record
• Epic

Team Members Involved

• Pharmacist
• Physicians
• Primary Care Physicians
• Specialists

Workflow Steps

• There were only minimal changes made to the physicians’ daily workflow other than ordering an extra CT (the order for which implemented in the EHR so no additional work is required) for eligible patients who met the following criteria:
  • Age 55-80 years old
  • 30 pack per year smoking history
  • Current smoker or former smoker quit in the last 15 years
  • Asymptomatic for lung cancer
• When they arrived for their regular care appointments, eligible patients (according to medical history) were identified as eligible for a screening which would entail a follow-up CT. Whether patients agreed to undergo lung cancer screening or not was their own choice.
• The Medical Assistants played a significant role to ensure that the workflow was triggered appropriately by obtaining and documenting accurate smoking history.

Budget Details

• Equipment costs associated with additional CT scans
• Labor cost of additional time spent by providers following up on CT scans
• IT costs associated with integration of lung cancer screening tool into the EHR

Where We Are

• Date (Month/Year) Project Described Started: February 2018
• Date (Month/Year) Paper Published: April 2019

Outcomes

• In the first year of implementation, 2505 patients met the eligibility criteria of a lung cancer screening and triggered a “quality alert”.
  • For 1085 of these patients (43%), a CT order was placed.
• For 883 of these patients (35%), the CT screening process was fully completed.
• Pertinent background information on lung cancer screening:
  • The NNS (number needed to screen) to detect one case of lung cancer is 123 (New England Journal of Medicine 2011).
  • The NNS to prevent one death from lung cancer is 320 (New England Journal of Medicine 2011).
• 68 patients (7.7%) who received screening had imaging results concerning for malignancy and required further diagnostic testing.
  • 54 patients (6%) had incidental findings (clinically significant findings unrelated to lung cancer, e.g. aortic aneurysm).
  • 4 patients were confirmed to have lung cancer and are undergoing treatment.

Future Outcomes

• Future steps include conducting PDSAs (see Glossary) to enhance adoption of the lung cancer screening process across more clinics.
• Valley Medical Center also plans to develop a standard workflow for management of patients seen by pulmonology when being monitored.

Benefits

• By screening earlier, the intervention reduces mortality associated with lung cancer, cascading to better quality of life and reduced medical costs.
  • Even with the additional cost of screening, the hospital still reduces overall costs due to the cost saved from chemotherapy and other expensive cancer treatments.

Unique Challenges

• Multiple handoffs (primary care, pulmonology, and imaging) must be integrated to ensure patients receive all steps of the lung cancer screening pathway and are informed of the results.

Glossary

• PDSA (Plan-Do-Study-Act):
  • After a team sets their goals and conducts measurements to detect if intervention changes leads to improvements, a PDSA cycle tests changes in the real work setting. It consists of 4 steps:
  • Plan: Develop a method for collecting data.
    • This includes stating the objective, making predictions about results, and developing a plan to test the change (Who? What? When? Where?)
  • Do: Try the intervention on a small scale.
    • This includes carrying out the intervention, documenting problems and unexpected observations, and beginning data analysis.
  • Study: Analyze the data results.
    • This includes completing data analysis, comparing data to predictions, and summarizing/reflecting on what was learned.
  • Act: Refine the changes based on what was learned from the study.
    • This includes determining what to modify and preparing a plan for the next intervention.

Sources

• Ingale, Sahana, et al. (April, 2019). Impact Analysis of Ambulatory Care Pathway for Lung Cancer Screening. Poster session at the Institute for Healthcare Improvement Summit on Improving Patient Care, San Francisco.
• Science of Improvement: Testing Changes, Institute for Healthcare Improvement
• (2014): Cancer Facts & Figures, American Cancer Society.
• (July 2015): Final Update Summary: Lung Cancer: Screening, U.S. Preventive Services Task Force. 
• (2011): The National Lung Screening Trial Research Team, “Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening,” New England Journal of Medicine, 365.