Webinar
March 24, 2018

Improving Lung Cancer Survival in the Community Setting: Nodule Management, Screening, and Program Development

SCOTT SKIBO, MD
| Haywood Regional Medical Center

Haywood Regional Medical Center, a 159-bed community hospital in Clyde, North Carolina, is nestled in the Blue Ridge Mountains right outside of Asheville. When Pulmonologist Dr. Scott Skibo joined Duke LifePoint in February 2017, his major focus was to grow the lung screening program and build a pulmonary incidentaloma clinic. In doing so, Haywood screened almost 400 high-risk patients and built a busy nodule clinic, improving lung cancer survival in the community.

In our March Ask the Expert Webinar series, Dr. Scott Skibo, shared his expert experiences in nodule management and screening program development, and how implementing these services improved lung cancer survival.

Transcript

I appreciate everybody for taking time out of their day to log in to this webinar. I certainly know that everyone’s time is valuable so certainly appreciate your time.  So, today well the title of my talk is “Improving lung cancer survival in the community setting, nodule management screening and program development”. Basically, what I want to do today is explain the program that we built in Western North Carolina. So, this is a map of the state of North Carolina with all the counties in North Carolina.

What is circled in red is essentially our practice, our geographical region that is the Blue Ridge Mountains Smoky Mountains, a very rural area of North Carolina. The largest city in Western North Carolina, many of you knows is Asheville North Carolina which is located in Buncombe County. My practice is located in Haywood County which the little red and black star is where I’m located.

So, everyone knows that lung cancer is not a good thing. It’s the number one cause of cancer-related death in the United States and it kills more people each year than breast, prostate, colon and pancreatic cancers combined.

We’re certain that our population is aging; we’re starting to see more lung cancer as a result of that. Unfortunately, nationwide we continue to diagnose more stage three or four lung cancer than stage one or two and unfortunately, this carries a very poor five-year survival rate. So, a very true statement that Doctor Carbone stated.

He stated, “At present lung cancers is recognized late. Opportunities to improve survival are through earlier detection, accurate diagnosis, accurate localization and curative therapy.”

Now unfortunately, this wasn’t just said two years ago, this was said nearly 50 years ago and it has remained true for almost 50 years. It’s only in the last few years that we’ve really started to move the needle on diagnosing these cancers early. Because we know if we can diagnose these cancers early, the 10-year survival of stage one is 88-90 % versus we know it’s bad at stage three or four.

So, the question is, how we get from the current state which is 85 % or so cancers being diagnosed at stage three or four; to the ideal state, which would be great if 85 % of our cancers will be diagnosed at stage one or two.  So, that’s the task, is to move from current state to ideal state in lung cancer.

What we already know is that there was a trial in 2011, the National lung screening trial that taught us a few things. So the first thing it taught us is, well hey, if we screen our patients for lung cancer 70 % of what we’re finding that ends up being cancer is early stage lung cancer and we only need to do about three hundred twenty scans to save one life with lung cancer and which represents a 20 % decrease in mortality and according to the people that run the numbers on this, it’s actually cost-effective to screen our patients for lung cancer; $81,000/- per quality adjusted year in comparison with no screening.

I guess the bar is, it has to be less than a hundred thousand dollars per the experts in order for our screening study to make sense and so this compares very favorably to mammograms and colonoscopies.

So, has this happened in the United States? In 2013, the US Preventive service taskforce updated their guidelines recommending yearly screening for lung cancer. Medicare and insurance has approved this test and I don’t think anybody’s going to argue that detecting lung cancer early is not important and I don’t think any if anybody’s going to argue the importance of managing our incidental pulmonary nodules. So that being said, what happened; well unfortunately, fewer than 4 % of our high-risk patients actually get screened.

This study published in JAMA oncology in 2017, kind of looked at before the USPSTF guidelines in 2013 were released and after. So before in 2010 they found that 3.3% of high-risk smokers were screened in the previous year. Then the guidelines came out in 2013 and in 2015 only 3.9%. So really didn’t change which in actual numbers of the 6.8 million current and former smokers that were eligible for screening, only 262,700 people were actually screened. Certainly, much worse than we should be doing.

So, the two questions really are, why is the rate of screening high-risk patients so low? I mean after all this is an evidence-based guideline recommended and Medicare approved test. The second question is what can be done to change this?

So, the first group I want to look at its providers, right and then we’re going to also look at the patients and kind of try to figure this out. Taking a look at the providers why is the screening rate so low?

A study published in cancer in 2016 looked at the knowledge and attitudes of family physicians using low-dose CT for lung cancer screening. Now most of the providers felt that in fact 98% felt that it increased the odds of detecting the cancer early. True! 75% felt that the benefits outweighed the harm and 76% thought that the risk benefit or discussed risks and benefits with their patients in some capacity. However, they felt really good about it but more than half made zero or one screening recommendation in the prior year to the study being performed.

Furthermore, there was a study performed that looked at primary care providers in an academic medical center. So interestingly this study was conducted at one of the centers that participate in the NLST trial. This found that few primary care physicians ordered lung cancer screening, all the ones that did more actually ordered x-rays than CT scans and some actually ordered sputum cytology, less than 50 % of primary care physicians could identify three or more the six guideline components for screening and a quarter of them knew zero.

So, what this identifies is that there is a definite knowledge gap. And one of the things of lung cancer is a fatalistic attitude of lung cancer with providers and patients. So, despite the data and despite providers feeling positive that we could find these early, 30% of the providers doubted the effectiveness of screening and improving outcomes. So yeah, we can find them early but we’re not going to be able to do anything about it once we find it or actually improve our patient’s ability to survive their lung cancer.

So, what are the factors associated with CT screening utilization?
Certainly, the lack of knowledge leads to a lot of inappropriate referral rates in our practices. In this study from 2013 to 2015, 37% of the low-dose CT scans that were ordered were inappropriate. Well I think this is a problem for a few things. Number one the more difficult it is for providers to order a test the less like they are going to try to order another one down the road. So, I think that leads to less tests being ordered and ultimately less patients being screened. And the other thing that was found in this study is that the majority of providers are unsure whether this is actually covered by Medicare. The good news though is that most providers want to learn more about lung cancer screening.

So, what has been learned with providers?
Number one, there’s a documented disconnect that’s well established in literature of moving clinical research findings into clinical practice. Probably the best-known example to this is the 1981 beta block or heart attack trial that took decades to find its way into practice. So again, the low dose CT scan for screening, this is an evidence-based guidelines recommended, Medicare cover test but it’s not yet made its way into routine practice. Physician knowledge is not optimal, we know that! There is a physician belief that low-dose CT is valuable for early detection but less believed that it actually makes a difference in mortality, so a fatalistic belief and most a lot of physicians believe that it’s less beneficial than other screenings, mammograms, colonoscopies etc.

Shifting to patients, why do patients adhere to screen?
60 % of patients in this study, if their provider recommends a screen they’ll show up to the screen.  Turns out that if they’re, the younger you are if you’re white and if you’re female, you’ll have a trend towards better adherence. There is actually no difference regardless of cancer history, residential area, level of education, insurance, occupation, provider location. Now the ones that did not adhere. So most of those patients 79% said, ”hey, I’m not going to do it now but I’ll do it in the future at some point”. That leaves 21% that just got an order for it but decided they didn’t want to go through with it. And if you look at why that is, well there’s that fatalistic belief in cancer, well I have cancer there’s nothing that can be done for it, so why even find out about it, fear of radiation exposure, anxiety related to CT scans. Very interesting I find is if you look at the smokers. So, if you have somebody that quit smoking or smokes less than they previously did they’re much more likely to show up for that screening scan. And this is very consistent with the data that smokers are less likely to seek out care for lung cancer. So, I find that data very fascinating and it really drives home the point that our smoking cessation programs need to be more effective.

So, what can be done to improve the screening rate?
Well number one, provide education. So fortunately, 82percent were more interested in learning about low-dose CT scan. Now in this survey 59 percent would prefer an online lecture, you know, lasting up to 30 minutes. It’s suggested that the focus should be on mortality reduction in CMS coverage and then also there’s data on in-office decision aids and then secondly patient education. So once again the decision aids, there is data that if patients are empowered to have the Information, to have this discussion with a provider, they’re much more likely to get to adhere to screening. Didn’t have this ordered and then community outreaching advocacy. All right, so there was a study getting back the decision aids performed in Asia which said providers who discuss the benefits of low-dose CT scan screening with the use of shared decision aids increased screening participation from 10 to 95%. Well I think that’s certainly a huge number and I don’t think they’re that effective but nonetheless I do think they’re effective when we’ve seen that in our practice.

All right so I’m going to shift gears to the incidental pulmonary nodule clinic and then before I get into our data. I was fortunate enough to be involved in what I believe is the first system-wide incidental nodule program in the country in 2013. At that time, I was working with Dr. Jennifer Mattingly who certainly deserves the vast amount of the credit for this program but we certainly work together on this. And the reason we did is because there’s an institution driven initiative to do this program because we knew that patients are falling through the crack and there was a medical legal risk. We were tasked and again I’m giving Dr. Mattingly the credit for this, of doing a retrospective chart review, where we reviewed nearly a thousand patients charts to see what happened if pulmonary nodule was found incidentally. So what we found is pretty sobering, we found that only 19% of patients were followed appropriately, 20% of patients are actually unacknowledged. So, the radiology report came out and not once there was a mention again in the patient’s chart that this study was ever done. 18% were referred to pulmonary but some of these patients never showed up in pulmonary. Some of them showed up in pulmonary didn’t adhere to further CT scan recommendations, 19% were outside patients so we weren’t able to find out what happened to them and then 24% were acknowledged put at risk for loss of follow-up. So those patients their primary care physicians discuss these findings with them but then they never had the CT scan or they never followed up with it again.

So, what did our clinic look like?
It started with the radiology report that had a pulmonary nodule. Now one of the hardest things initially in setting up this program is we had to ask radiology to change their workflow so I’m going to just skip to the next slide and then come back but what we asked radiology to do is to change their report and we asked them to put several things on it so we could risk ratify our patients essentially in and put them into high, moderate and low risk categories and make sure that they’re receiving appropriate care. So, this took a lot of work and a lot of meetings and then to get radiology to adhere to this and to do this. But once this was done we’re able to start our lung nodule clinic and so the radiology would report this, it will then come to the nurse navigator who reviewed the report, calculate the patient’s risk, contacted the patient, the navigator then facilitated an appointment with either pulmonologists or a primary care physician depending on risk Factors. The pulmonary provider evaluates the patient, patient undergoes appropriate testing data is entered into the database, navigator ensures appropriate follow-up and that the patients moving through the process and then lastly reporting the quality data.

So, what did we find?
This clinic began in August 5th, 2013 to date greater than 4,000 patients identified and entered into the pulmonary nodule database, on average 164 new pulmonary cases per month which 57% of those were deemed high risk. So the point here is this data can become overwhelming because it’s 164 patients on top of 164 patients on top of 164 patients and that just adds. So early on when we’re trying to do things with a spreadsheet and then homegrown software it became very difficult to manage these patients.  So, what did we do now in Haywood County? So, Haywood Regional Medical center, we sat down and our overall program goal was number one, improved lung cancer survival in Western North Carolina so that was our one and only goal in everything that we did had to help us reach this goal. So, there’s several components to our program and I think several components that make any program, so lung cancer screening and pulmonary nodule clinic of course what we’re talking about today but in order I think to have a good quality program you have to be able to do something of these Nodules.

So advanced diagnostics and therapeutics, multidisciplinary lung cancer team, quality improvement, so we’re constantly looking at our stage shift, diagnostic yield from our procedures, adherence low dose CT scan, time to treatment etc. Awareness and advocacy and lastly a smoking cessation program as part of this comprehensive Program.

 

So, we knew as we’re building this we need to reach the physicians that we’re going to refer to us. So, over the past couple years we were able to visit most of the vast majority of the urgent cares and primary care physician practices in Western North Carolina. So, this is just all the counties in western far western North Carolina. Again, our practice is the hospitals right here in Haywood County, the blue one right in the middle the stars all represent individual practices that I visited in the last two years. So generally, these were breakfast meetings or lunch meetings to discuss, nodule Management, the lung cancer program, advanced diagnostics and therapeutics, essentially but to meet these people and let them know what we’re doing. We also had to raise awareness in the community. So in the in the past couple years we, as a program, have written a several newspaper articles for our local newspapers describing what we’re doing, raising awareness patient advocacy. Anytime we had the opportunity to get on local television in Asheville, we took that opportunity to talk about lung cancer screening, advanced diagnostic programs that we have, community events, we’ve been partnering with lung cancer alliance for the past few years to run a shine light program in Western North Carolina, other things that we do at Haywood Regional Medical Center or talk with the docs you know an evening dinner in a discussion and which is various topics but certainly lung cancer and what we’re doing with lung cancer at Haywood Regional is has been one of those topics.

 

And then lastly shared decision-making Materials. So, I think this is a really important thing this pamphlet now as of this past summer sits in every primary care physicians office in our network as well as my office and it allows the patient as they’re sitting there waiting for the doctor to come in for an appointment to grab this pamphlet and read through it and then have a thoughtful conversation with the provider. Secondly it does a second thing. So, the criteria for screening are listed right in this. So, what it’s, what I believe it does is it decreases the inappropriate referrals because the criteria are sitting right in this pamphlet. So, I think this is definitely a key piece of having patients that actually adhere to screening. The number two, screens that are sent in that are appropriate screens.

 

So, what is our data look like?

So, looking at 2016 when we started our screening program to 2017, so, in 2016 we did 96 total screens and we’ve diagnosed two cancers, in 2017 we did 269 total screens of that we’ve diagnosed three cancer. So, about what you’d expect from the NLST data or from the screening data, you know maybe just a tiny bit higher than that. But of course, my practice resides in the tobacco belt and there is a higher incidence of lung cancer. So, looking at the same data on a month-by-month basis.  So, this is on the bottom on the x-axis is January to December so those are the months and on the y-axis is number of screenings done per month and then the two years are side-by-side. So, the blue ones are 2016 and the green ones are 2017.  So when we started our program we have everything ready to go and in January of 2016 and one person got scan and this could be one of the things that really makes people lose enthusiasm for a screening program is you put all this work into it and then you’re not screening anybody but as time went on we started to see more and more patients but then as we did more outreach more provider education, as we move into 2017 you see that the numbers month-to-month have increased and then in this July of 2017, which is here, you see a significant increase that’s  a state increased in and looking at our data and the reason for that is just the process that we had. As far as scheduling these CT scans we made it a much more efficient process and so that one changes that we made in efficiency increased adherence to this program significantly with our patients.

 

So, the incidental pulmonary nodule clinic. Now in 2017, the total reports that were flagged were 125 and from these flagged we diagnosed 20 cancers. In 2018, we went live with EonDirect (formerly lungdirect). On the first two months, 51 incidental nodules were flagged, of that we diagnosed 7 lung cancers. So, if this continues for the rest of the year that’s going to be over 300 patients. So that there the question is why is that?  I put up on the right-hand side of the screen the data from Dr. Mattingly and myself as far as what are the possibilities this has nothing to do of course with what we found in Heywood but I think there’s a lot probably more than 19% or had been followed appropriately you know but there’s some that are unacknowledged, you know that’s read by the radiologist unacknowledged. We had to rely on these being flagged by radiologists from the radiologist to put into a basket that was then the Navigator had to then go retrieve from the basket and so you had all these different human interactions that I think led to a decrease in the number of flag reports that ended up in the navigators in basket.

So fast forward to 2018 we’re seeing a lot less of this as a result we’re capturing much more of our incidental nodules.

So, what does this mean though?
So, you know before we started the program – because what we really want to know is, what are we doing to increase patient survival with lung cancer. So, a pre-program starting, 20% of our patients were Stage one or two, so very consistent with national data that most of our patients for Stage three and four you know that in a much smaller number of cancers. After our program started we saw a significant stage shift, so now 56% of our patients are stage one and two. Furthermore, looking at all of our patients in 2017, that were diagnosed with non-small cell lung cancer, 54% of these went on to either get surgical resection or stereotactic radio surgery.

As a result of this work we were fortunate enough as a hospital to receive the 15th community hospital in the nation, to receive the bonny J Dario foundation community center of excellence designation and this is certainly, a good time to make sure that everyone realizes that this is a team effort and this could never be done without excellent radiology and administrative radiology support and overall administrative support, an upfront navigator in the navigator team, pathology as well as the medical oncology, radiation oncology, thoracic surgery and then of course pulmonary. So, it’s certainly a team approach.

So, what have we learned?
Number one, an incidental nodule program grows exponentially and really if you’re trying to use spreadsheets manages it’s nearly impossible because the data is it just keeps on growing and growing and growing. Having a front-end navigator is essential. So, in our program, we’re a small Hospital but we split the duty. So, we have a front-end navigator that that works up to cancer diagnosis. She’s actually my procedural assistant as well. And then we have an after-diagnosis navigator. So, Amanda beforehand and then Johanna after. And this is essential I think, to have somebody that’s dedicated the front end because this workload grows. We’ve learned in my previous practice as well as now that an incidental nodule program that relies on human input is going to miss patients and also, I think it’s very difficult to build these programs without the appropriate people involved. So, a physician champion, I think is essential. It does not have to be a pulmonologist it certainly could be, it doesn’t have to be a physician I think this could be an administrative champion. In certain places you need a navigator. You know administrative support, radiology support because you’re asking radiology potentially to make some changes. Now with this have become minimized or actually has become non-existent with the software programs of EonDirect (formerly lungdirect) but that was certainly always the case and then there’s strength in numbers. No hospital can do it all by themselves. So, we’ve partnered with other organizations to improve patient care access, the Bonnie Addario Foundation, North Carolina lung cancer initiative, lung cancer alliance, education to providers and community outreach is important and works. We’ve seen our numbers improve. We’ve seen the number of referrals for lung cancer screening increase as a result, I believe of doing this. The physician aids the patient, the visual aids I believe also helped that.

Submissions to the ACR are difficult for low dose CT screenings and they’re cumbersome. I think this has been well described in the literature as well, these get kicked back all the time if you missed one thing in them. I think a much more efficient way to submit these is automation and so we’ve certainly learned that the hard way as well. Scheduling screening low dose CT’s is more time consuming. When we saw our bump in low dose CT screens in July of 2017, it was a direct result of changes that were made in the scheduling process. And the thing that we continue to struggle with there’s a program is smoking cessation. It’s certainly the biggest challenge that remains in our program. We’ve tried multiple different things and we’re still looking to build a very successful smoking cessation program. You know, but this is definitely has been one of our biggest challenges. So, this is a picture of you know, this the Blue Ridge Mountains and we’re where I believe Heywood Regional Medical Center may be located. I just took a guess there but this is what it looks like where I live and fortunate enough to practice there and call this my home here but that is what I have to say. I’d like to open it up for questions.

Question:
Do you have any issues with the radiologist recommending a six-month follow-up screening LDCT?

Answer:

Dr. Scott Skibo:
No in a negative or lung rads 1 we have not. So our radiologists are excellent at adhering to the current guidelines of annual screening.

Dr. Aki Alzubaidi:
So, just to be clear and this may be common knowledge but lung rads 1 and 2 get a 12 month annual CT scan and then lung rads 3 would have a six month follow-up. Anything that’s not an annual, is scheduled out in 12 months per the ACR is considered a follow-up. So, it doesn’t matter if it’s a three months it’s a 4A or it’s a three-month follow-up is recommended. If it’s a long rads 3, it’s a 6-month follow-up and then lung rads 2 and 1 are considered annual and you don’t use the word follow-up I don’t know if it makes sense or not.

Question:
The number of screens done in 2016-17 were these all initial screens or a combination of the initial, annual and 3, 6-month follow-up.

Answer:

Dr.Scott Skibo:
The vast majority were initial screen. So one of the problems, one of the struggles that we’ve had as a program is getting primary care physicians and our patients to adhere to that second follow-up screen with the lung rads 1 or 2 screen, and so it certainly is going to add to our 2017 numbers without question but it’s a relatively small percentage. One of our initiatives moving forward is going to be better adherence to follow-up screens.

Dr. Aki Alzubaidi:
So, Georgia does look like it was probably a combination and there is a huge amount of drop-off and just so you know the 90% of people who go into lung cancer screening will get an annual follow-up. So, in terms of the numbers the majority of those patients were the annual follow-up and we’re likely not included in that aggregate number for that slide I’m assuming.

Dr.Scott Skibo:
Right.

Dr. Aki Alzubaidi:
And then like Dr. Skibo said – there’s this thing called risk of never follow-up and there’s actually new data now that shows that if let’s say you’re scheduled for a three-month follow-up and you haven’t had that three-month follow-up the patient never came in for the CT scan and it’s 30 days past that three months they’re at risk of never follow-up like huge risk of never following up. At six months it’s 45 days and at one year they haven’t add it within like three months of it being due then the risk of never follow-up is greater than 90 percent. So really important to communicate with your patients within a window of when the actual follow-up or annual is due and then when they don’t come in, so normally most people wait you know no more than two weeks to communicate that “hey, you missed your scan” and try to get them to come in for that annual three six or other follow-up.

 

Question:
On one slide. There were two patients diagnosed in one year and three the next year but multiple lung rads of three and four!


Dr. Aki Alzubaidi:

So, I think this is asking a question about if you have a patient who’s in the higher risk category the higher pretest probability, why don’t you have more cancers right?

Answer:

Dr.Scott Skibo:
Yeah, I’d like your opinion here to Aki but I think, you would expect especially lung rads four a lot of these to end up being cancer, certainly not all of them are and some of these the lung rads three and four you could just use our followed and end up being diagnosed with cancer in a timeframe but you know the data is the data.

Dr. Aki Alzubaidi:
Well here’s the thing too is that I think that lung rads one, two, three, and four a b and x, don’t necessarily put a pretest probability on each of those nodules and so you don’t know in terms of a lung rads three I think that you would probably we could get the real numbers of how many lung rads threes actually had cancer and in this patient population the rate of cancer is very very low. If you look at the whole overall anybody who’s a lung rads one, three, four, just because you’re a lung rads three or four doesn’t mean that you should have you know over fifty percent of those patients who actually get diagnosed with cancer I think the lung cancer like actual rates and three and four are quite low and James I’ll get the real numbers on that and we can send that to you. I’ll get you the exact numbers of the lung rads three and four that actually correlate to cancer in the NLST trial.

Question:
You mentioned change in process that increased lung cancer screening adherence, can you say again what that change of process was?

Answer:

Dr. Scott Skibo:
Well essentially the biggest thing that occurred was one person took ownership for that. So I think it’s some very akin to, if you have two pulmonologist and there’s a big stack of pulmonary function tests to read in a big stack of cardiopulmonary stress tests to read and they’re both responsible for that, the PFDs are going to get done first right. So these scheduling these tasks the low-dose CT scans is more cumbersome then scheduling just a regular CT scan. So there’s a little bit more work to make sure that these are appropriately scheduled tests and so because of that I think it got put to the back-burner at times and so there is patient dissatisfaction because primary was send in an order and then it wouldn’t get scheduled initially and then we had I think that’s why we saw drop-off and as soon as that process was fixed we saw a much better adherence.

Dr. Aki Alzubaidi:
Intake stuff still, I think that you know you got to think about it that you got to have some sort of documentation that there’s a shared decision visit but there were smoking cessation and at the patient meets inclusion criteria. Like you said I saw one of your slides earlier saying about how many lung cancer screens were done on people who are actually ineligible and there was new data that after talking to Deb Dyer and she’s saying that maybe up to 60 % of patients who are screened may actually be ineligible which is a huge number.

I don’t think we actually know the exact number but I think that intake centralizing scheduling these are things that we’re still trying to figure out on a big scale.

Dr. Scott Skibo:
I mean just a study I cited in this talk was 37 % so it may be higher than that but a large number without question.

 

Question:
Which type of reports were include in identification of nodules. Were these just low-dose CT screens or do they include all the other CT scans that you can think of?

Answer:

Dr. Scott Skibo:
Everything. Basically anything that you’d see a nodule on was included in this, so it’s actually if there’s a nodule we want to know about it right and then we can work it up appropriately from there but whether it is Chest x-ray, whether it is an abdominal, and CT that gets the lower lungs, whether it’s a chest CT whether it’s a low-dose CT scan we want to know about it and so it is essentially any study that has a nodule.

Dr. Aki Alzubaidi:
And Heather just to expand on that I’ve seen oh it’s a week you know I’m lucky enough to go around and see a lot of people’s different shops and how they do things and it’s really the non LDCT scans that have to have those reports. Because the low-dose CT scans usually reported with the lung rads and so that would let you look like a lung rads designation you can pull that pretty easy and you can track nodules that way for lung cancer screening patients. The big difficulty to me is trying to identify the patients who are not in the low dose CT screening cohort. It’s the incidental nodules. So, you’re right the chest CT is a 71250. The CT angio, the CT abdomen, pelvis the CT, next they go into the ER they look for a blood clot. So ,if you do a CTPE study you’re 2 times more likely to find a pulmonary nodule then you are a blood clot and so those are the patients that really need these reports to be identified because they’re the ones who I think are really slipping through the cracks.

Question:
What is your process as far as reminder calls and letters to the patients?

Dr. Scott Skibo:
Well since we went live with EonDirect (formerly known as Lungdirect), with EonDirect it’s now all automated and so I guess Aki can answer this question much better than I can but it’s become an automated process which I think is an essential piece of a program because the work load becomes tremendous that you know as you follow these patients you just gather patients and gather patients and so you have such a database of these patients that if it’s not an automated system, things are gonna get missed and so yeah it’s a completely automated process at this point.

Dr. Aki Alzubaidi:

Yeah and that’s getting better too. I think that what you can do is you can automate and if you don’t have software just try to do this on your own, I think that you template out different letters and so you have a lung rads one, lung rads two, lung rads three. You have an initial you have a follow-up and then you have if they missed and you have it from the PCP and to the ordering physician and the patient. We have templates and I can actually, Rachel if I’m saying your name right I hope I am, we can send you templates of letters that you can use for that process and so you don’t have to have software just send letters and communicate, we can give you templates too just so that you can start that process and our recommendation would be that you have multiple templates at your disposal that you can do based on the situation.

 

Question:

Any advice on how to convince the hospitals to fund a database that would help track the lung nodules and lung cancer screenings?

Answer:
Dr. Aki Alzubaidi:

This has become my life right so I think both of us you know have gone through a situation where you’re passionate about not having patients who had a CT scan and then they later show up with late stage cancer. And so, I think that the importance of tracking lung nodules does take time, it takes FTEs it takes effort and work. And so to me it’s really starting that program and tracking it on your own at first is how I did it personally at my previous practice and then watching everything that happened downstream and now we even have a product (EonDirect) so now when we try to help people get eondirect (formerly lungdirect) is that we do a pro forma. we have a generic proforma that I can share with you Karen that can show like if you had this many lung cancer screens or if you had this many nodules here’s the revenue that’s gonna be brought to the hospital and that should help you get some resources. You know not just, funding the database but funding the resources to really you know have a complete program that Dr. Skibo talked about. We ended up at my shop, they ended up getting a new SPRT machine and like they hired a radiation oncologist and a thoracic surgeon and because of the revenue that was generated straight from nodules.

Dr. Scott Skibo:
Yep I agree.

Question:
In our program here in Brooklyn New York, we took on the responsibility of scheduling patients for the annual screens, we contact them directly and then contact the referring MD for the order. I don’t think that’s some abnormal view

Answer:

Dr. Aki Alzubaidi:
Yeah I think that’s normal. So we had a talk last month about centralizing the scheduling and to me I think that’s very smart just because the same thing that you would talk earlier

Dr. Scott Skibo:
Absolutely I agree with that you increases adherence. Absolutely!

Question:
Scott great talk, good work in Western North Carolina. Can you tell us what you have done to streamline, this everybody is trying to figure out the scheduling process?

Dr. Scott Skibo:
Yeah well again, it this is answer previously but again it’s having one person take ownership for this instead of just a big bucket of general work that everyone has to help out with. If one person has ownership for this process it gets done and that’s what we found in our shop. Now again our systems not going to apply to everybody because again, I know we’re a small Hospital hundred fifty-nine bed hospital but it works. If you give, alright, our small team of people that this is one of the responsibilities, I think ,that certainly has helped us tremendously and I think the data on our adherence to screening would support that in.

Dr. Aki Alzubaidi:
Roger we can, we can we can catch up to offline on some things that we can help you with on a systematic fashion to with centralizing the scheduling. A

Question:
What obstacles of any do you have with shared decision-making visit for the LDCT screening patients?

Answer:

Dr. Scott Skibo:
That’s a good question! I guess obstacles that we’ve tried to really overcome are, I think it all starts with the primary care physicians and because they have more impact on preventative care than a pulmonologist ever will. So the obstacles that we have tried to overcome is an educational barrier, you know the educational deficit and our shared decision-making literature that we put in everyone’s office I think has certainly helped that because it’s educated the patient as well as the provider.

Dr Aki Alzubaidi:
You put that in the PCPs office?

Dr. Scott Skibo:
PCP’s office and exam room, so that’s in the exam room.

Dr. Aki Alzubaidi:
Did you go there yourself and put it in their office?

Dr. Scott Skibo:
I can’t take credit for that we have a great marketing and physician liaison thing that that took care of all that so I certainly would not take credit for doing that but that was a great idea.

Dr. Aki Alzubaidi:
That’s really a great idea!

Dr. Scott Skibo:
See because again then, when patients are sitting there in the exam room, doctors often running a little bit late, they read through the literature that’s in there and one of the things you’re going to read through is that it catches their eye especially if they’re a smoker. And I think that’s been a really good tool to facilitate discussion and to make sure that patients are aware of the data behind screening.

Question:
Did you say once the incidental nodule has identified; the navigator contacts the patient or do they notify the physician first to order the scan. I found in the ER, I usually notified the PCP who was listed in the ER physician record.

Answer:

Dr. Scott Skibo:
Both are actually contacted. This was data from my practice in Wisconsin. We did take it upon ourselves to contact the patient. We felt as a team that the patient, this is information they need to know. We felt that the more people that knew about this the less likely it was to fall through the cracks. But we certainly knew the importance and realizing importance of making sure the primary care physician was in the loop and driving the ship.

Dr. Aki Alzubaidi:
So I have some questions Scott!

  1. SCOTT SKIBO:
    oh boy.

Question:
There’s been places that have wanted to set up a lung cancer screening program who don’t have all of the components that you listed to succeed. And so what I like to know and we actually have we set up a system at a critical access hospital that was you know really 0 beds. So what I want to know is, if somebody, who knows where anywhere wants to set up a lung cancer screening program they don’t have all of the components can they do it? should they do it? and how can they do it?

Dr. Scott Skibo:
I guess the way that I answer that is yes, because you have to start somewhere. And I think if you start with, well let’s start following our incidental nodules and lung cancer screening. I think the necessary component is a nurse navigator but let’s say you don’t have an advanced bronchoscopy or you need a plan to do something with the findings that you find, right. So, if you get a lung rads 4 patient or if you get something that’s worrisome that needs a procedure done what are you gonna do with these patients because you will find those patients and so going into it you just have to make sure there’s a plan of where these patients get sent if they can’t be dealt with in the current setting so as long as there’s plans put in place. But then I think would in my opinion what would be found is that the business that you get from this, how busy you get doing this, it facilitates acquiring the other stuff so I think it’s you shouldn’t have to wait till you have everything in place to start a program. I think starting a program helps you get everything in place. Yeah but in the meantime though you have to just make sure there’s a plan of how you’re going to manage these patients when you get positive findings.

Question:
As a hospital that may have double to even triple of your incidental nodule volume, would you anticipate EonDirect (formerly LungDirect) able to support that volume and see the success you have seen?

Answer:

Dr. Scott Skibo:
Well that’s a hard question for me to answer knowing that I just work them. I think that my personal knowledge is, I know, that EonDirect (formerly lungDirect) is in hospitals that are much bigger than mine, so Aki is gonna answer that part of the question. But I think it’s a very scalable thing. I think that it decreases the amount of work that a navigator needs to do significantly so your FTEs that you need managing these nodules goes down. So, you know if I doubled in size, would I need another navigator, potentially! So would I need 2 software systems? No. I mean, so what I need 2 navigators now front-end and if I didn’t do EonDirect probably you know so the overwhelming at this point.  Even in my size hospital to just have one front-end navigator. So my guess is that EonDirect would have no problem regardless of the size but I’m gonna let Aki address that one.

Dr. Aki Alzubaidi:
Yeah. We are in a critical access hospital all the way up to the Cleveland Clinic and who just expanded us out to all seven sites. So all seven of those sites are bringing in all of the volume into one centralized EonDirect software system and they went from you know I think you one to three hours per patient per year, down to five minutes per patient in terms of what they’re doing for data entry and some of their navigation. So you know, you can handle volume but it depends, you know you still have to have infrastructure and a plan. In terms of being successful like Dr. Skibo, we talked about this coming here is that there’s an approach and like, there’s a human. It’s not about the software just specifically. The software, it helps but it’s a tool. There has to be a person who’s a champion and I think that’s why Dr. Skibo has seen the success that he’s seen it’s that he’s dedicated and focused to championing everything that needs to happen and getting past all the roadblocks and all the speed bumps that will occur inevitably during you trying to set up a nodule program. Wouldn’t you agree?

Dr. Scott Skibo:
I would definitely agree but I do think there needs to be a champion but it doesn’t have to be a physician champion. I’ve seen a lot of, of course, most of my friends that happen to be pulmonologist. It seems so, I’ve seen a lot of good models or pulmonologists or the physician champion but I’ve also seen hospital systems where there’s an administrator that’s a champion so it doesn’t have to be a physician, it doesn’t have to be a pulmonologist. That just seems to be in the nodule world the most common physician champion, because the pulmonologist is often the person that is on the front end with the nodules.

Dr. Aki Alzubaidi:
And you make a good point. I mean, Amy Shae, I was bringing up she, she’s running that program over at TMCA and they have a kind of like a hub-and-spoke type setup, where there’s a you know a centralized kind of process. I think it’s really just looking at your environment and then looking at what resources do you have and then planning. And in every environment is just a little bit different and it’s really just creating something that you know all of these patients you segment them out into risk, you do the same repetitive behavior with all of your lung rads 1, your lung rads 2, your lung rads 3.

Question:
What if a patient is in the ER has a nodule and they are unassigned, there’s no PCP assigned right! Who do you contact then and what do you do with the patients who don’t have PCPs?

Answer:

Dr. Scott Skibo:
So that patient would automatically now get the navigator, would get notified. So right now, in our system I would default to see that patient but we would work on getting that patient to PCP. So as a system we would help arrange that. But as a nodule management, we would definitely manage that nodule. We would just take that on.

Final Notes:
If there’s no more questions, I think, this has been great. I always learned something with these and Dr. Skibo really appreciate you coming down here to the advanced bronchoscopy course here at the Cleveland Clinic Florida. Excellent information, if you guys would like the information that was presented here or a copy of this webinar, I know that Taj is going to be your contact. Don’t hesitate to reach out to us for any anything that you need in terms of templates, if you need proformas for your hospital, if you need general information on how to set up a program, I think that you know either one of us are more than happy to talk to you about on a one-to-one level. If you’re trying to do this I think a lot of people are trying to do this, there’s a lot of struggle. Dr. Skibo has been very successful. I feel like we know what we’re doing – and would love to share any knowledge with you guys so thank you guys so much for joining us.

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