As a physician, I’m always happy when new services can be offered to patients, especially when the benefit includes a 20% reduction in mortality, such as Low Dose CT Lung Cancer Screening. As it is widely known, the National Lung Screening Trial (NLST) conducted a large multi-center study to determine the benefits of screening in a high-risk population for the early detection of lung cancer. The results were promising enough for the trial to end early and CMS to determine lung screening beneficial enough to be covered. While great news for patients, the CMS requirements have made it difficult for hospitals to implement comprehensive screening programs.
When I started a lung screening program at my former hospital, I realized how difficult it is to properly run a program. Lung cancer screening requires complex patient eligibility requirements to be met, and a convoluted intake process makes it challenging for primary care physicians and hospitals to implement an ACR compliant program. The end result, we had everyone from compliance to marketing to my clinic staff working to manage our patients and ensure compliance.
The intake process starts with a Shared Decision-Making visit between a patient and an advanced provider, usually their PCP. Together they review the benefits and the risks, and the provider determines patient eligibility.
However, recent studies indicate there are still several gaps in provider knowledge regarding screening guidelines and reimbursement. Many physicians continue to recommend chest x-ray for lung screening instead of the required low dose CT lung cancer screening (LDCT).
PCPs were also less likely to feel confident in their ability to:
- identify appropriate patients for lung cancer screening
- decide the workup of patients with positive LDCT findings, and
- to believe the recommend yearly screening interval is feasible (https://www.ncbi.nlm.nih.gov/pubmed/28648531)
In addition, CMS requires current smokers receive smoking cessation guidance prior to being screened. Recent research shows smoking cessation has become a discipline in and of itself, and simply telling a patient to stop smoking is no longer sufficient due to the complex physical and psychological aspects of smoking addiction.
Once a patient receives the shared decision making (and smoking cessation guidance if applicable), the PCP refers the patient for a Low Dose CT (LDCT). Screening facilities must confirm patient eligibility, which requires extensive follow-up to determine the patient is between 55-75, has a 30-pack-year smoking history, and no symptoms of lung cancer. All information must be captured and documented, and eventually submitted to an approved registry,
Ninety percent of all screening patients will show either no sign or very low risk, of lung cancer and must prescribe to a minimum of two additional annual low dose CT lung cancer screening scans to ensure lung cancer does not present. This requires intensive patient follow-up, usually with an assigned FTE tracking these patients. Because EMR’s are not designed to track longitudinal care, Excel spreadsheets and calendar reminders have become the norm in patient tracking, and FTE’s spend over an hour per patient per year with a somewhat high degree of error and cost. In some cases, screening centers only track the initial CT because the resource necessary to track patient follow up is not available.
I am driven by the mission to ensure we manage 100% of patients per evidence-based guidelines, and while lung cancer screening as a benefit to patients is a good start, much work still needs to be done to ensure the right patients are identified and screened. Hospitals who innovate practical and consistent services, such as centralizing the shared decision making and smoking cessation guidance, or develop systems of communication to ensure the intake process is streamlined, will provide significant value to their community and patients. This is why I founded EonDirect and I invite you to join me on the journey to keep it 100.