1149 — Timely receipt of guideline-recommended annual lung cancer screening across three rounds among US Veterans
Lead/Presenter: Renda Wiener,
COIN - Bedford/Boston
All Authors: Wiener RS (Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System), Nunez ER (Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System) Qian SX (Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System) Zhang S (Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System) Boudreau J (Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System) Glickman M (Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System) Miller DR (Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System) Slatore CG (VA National Center for Lung Cancer Screening; VA Portland Healthcare System) Caverly TJ (Center for Clinical Management Research, VA Ann Arbor Healthcare System)
Lung cancer is the leading cause of cancer death among Veterans. The National Lung Screening Trial demonstrated a 20% reduction in lung cancer mortality with three annual lung cancer screening (LCS) exams. This mortality reduction was dependent on annual screening: lung cancer detection rates were similar throughout each round. Yet adherence to LCS in real-world practice may be suboptimal. We sought to determine how often Veterans receive three annual rounds of LCS and identify patient and facility-level factors associated with adherence. We hypothesized that Veterans receiving care at sites with an LCS coordinator would be more likely to receive 3 rounds of annual screening.
Using the VA Corporate Data Warehouse, we assembled a national retrospective cohort of Veterans who initiated LCS between 2015-18 in any VA facility, identified by presence of a CT chest with a report including a Lung-RADS (Lung CT Screening Reporting and Data System) code. We then assessed for the presence of a second and third annual LCS exam 10-15 months from the prior CT. Disqualifying events (those for which we would not expect a subsequent annual LCS exam) included high-risk LCS findings (i.e. Lung-RADS category 3 and 4) for which closer follow-up is recommended, lung cancer diagnosis, reaching age>80 years, or death before the next annual LCS exam was due. We calculated the proportion of Veterans who received a total of 3 annual LCS exams over a period of 3 years (allowing some room for delayed LCS). We then performed hierarchical mixed effects logistic regression analyses, with patients nested within facilities, and facilities as random effects.
Among 11,467 Veterans that initiated LCS, half (46%) received 3 annual LCS exams and a quarter (26%) had no LCS follow-up. Veterans that were racially Black (OR 0.82, 95% CI 0.68-0.98) or lived farther away from a VA facility (OR 0.86, 95% CI 0.81-0.92) were less likely to receive three annual LCS exams. Meanwhile, Veterans that had more frequent outpatient visits (OR 1.38, 95% CI 1.23-1.54) and those with initial LCS results categorized as Lung-RADS 2 vs. Lung-RADS 1 (i.e. likely benign nodule vs. no nodule detected) were more likely to have 3 annual LCS exams. At the facility-level, those with medium (OR 4.63, 95% CI 1.5-14.1) or high LCS volume (OR 6.5, 95% CI 2.4-17.6), or those facilities that used a LCS coordinator (OR 6.86, 95% CI 1.1-44.6) were more likely to receive 3 annual LCS. The facility at which a Veteran received their initial LCS was responsible for 34% of the variation in receiving 3 LCS.
In a national cohort of Veterans, there was suboptimal longitudinal adherence to annual LCS. Further, we identified disparities among Veterans who face barriers to access: Black Veterans and those that live farther away from a VA facility.
To achieve the life-saving potential of LCS in VA, it is critical to optimize adherence. Facility-level structures that support LCS (e.g. coordinators) can improve adherence to LCS and may be an avenue to address disparities among underserved populations.