Journey to (Lung) Screening Center of Excellence

Dr. Aki Alzubaidi:

Today we’re going to be talking with Tory Shepard and the title of her presentation is “journey to a screening center of excellence”

Tory graduated from ODU and got her Bachelors of Science in 2011. She is a registered respiratory therapist for 24 years from 1996 to present and has worked at Central Health in Lynchburg General, cone health and now SOVAH health in Martinsville.

She’s also the supervisor of cardiopulmonary and vascular services from 1998 to 2011, cardiovascular coordinator 2015 went on to become the director of cardiovascular ambassador services until 2016 and now she’s the assistant administrator at SOVAH Health Martinsville.

She has been the guiding light for Silva and in Southwest Virginia for the incidental lung cancer screening program. There has an immense amount of knowledge and there’s nothing better than experiential wisdom so Tori thank you for coming.

Tory Shepherd:

Thank you Aki, I appreciate it.

I hear and speak for my team as well and we’re so appreciative to have this time with you guys to go through our journey and the hopes that can help you as well.

Journey To Screening Center Of Excellence

As it states in the title, this journey for us has been for the last few years and we are not a screening center of excellence yet but we hope to be by the end of 2019. I like to start by talking about statistics that 18% represents the 5-year survival rate for lung cancer according to the lung cancer Alliance website and that’s compared to breast at 90%, prostate at 99 and colorectal at 65 percent.

I think that staggering 2%  is the eligible population in the United States to actually receive lung cancer screenings despite having large access.

25% that’s the lung cancer rate of death and if you compare that to breast and prostate, it’s  quite significant.

And then 16% is early stage detection of lung cancer. 16 percent is the eligible population that will be diagnosed in the early stage and so those are the statistics that I always start my conversations with because I think they’re so significant and unfortunately these have relatively been unchanged for the last number of years.

I actually worked at the bedside for 15 years so I understand all too well what our patients have to endure and so lung cancer continues to be the number one cancer killer in the United States. However, screening is certainly a game-changer.

So, I wanted to start with an image because it represents to me what what this looks like when you start your journey. There’s unpaved dirty roads with no lines or real direction, other than it looks long but at the end of this is this beautiful view and certainly that’s what we have found at the end of our journey as we starting to close on Mars.

Three Pathways For Detection Of Lung Cancers

With a lung cancer program, it’s important to have a comprehensive lung cancer program when you’re going to do your screening center of excellence through your journey. So what we found was that there are three very distinct pathways for detection of lung cancers.

One of those is patients that present with symptoms suggestive of lung cancer, so more late stage lung cancer patients.

The second is the low dose CT screening pathway and then the third being the incidental finding pathway.

It’s important to understand all three pathways because all three of those will have very different needs and in order to move forward with your journey to a screening center of excellence, you do have to have a comprehensive lung cancer program.

Considerations For Each Pathway Into The Program

It’s important to understand the unique barriers to screening and treatment of your population. Also, what is the technology in the physician support available you know what are you going to do with the lung cancer screenings once you start some power you going to close the loop. And then how are incidental findings handled if they are handled. Is there a central location for all lung cancer patient information to be housed? A multidisciplinary team is key to everything.

History Of Sovah Health: Martinsville Journey

We actually started doing for our Martinsville here in 1980. So that tells you how long we’ve been doing our diagnostic capabilities we’ve had to do some significant work and improving upon that through the years.

In 2015, we hired an interventional bronchoscopist and with him he brought in two bronchial ultrasound.

At that point in time our low dose screening program was in place, however, it was solely fee based and so it was rarely used. We had little to no marketing for community outreach in place.

Martinsville and Henry County

I spoke earlier about knowing the community you serve and for us and Martinsville and Henry County, our community has been historically built upon textile mills and furniture industry and some 20 greater than 20 years ago most all of that industry left marks on Henry County and that unfortunately has resulted in one of the highest rates of unemployment.

If I look to date and the the most updated information I found from the US Census Bureau was 2017 and if I compare that to the national rate of persons in poverty at 12.3%  and the state rate of persons in poverty at 10.6%

You can see that Henry County comes in at 16% and Martinsville is at 24% so just to give you some idea of the population that we serve here in Southwest Virginia.

Engaging Martinsville/Henry County

In 2016 I entered into a year and a half long research project with Virginia Tech and and Carly Rousey and Dawn Moser were the the leads. They actually did the epidemiology search and what was found was that there is a highest incidental death from lung cancer in the West Piedmont district of Virginia here at Martinsville and Henry County.

So that was pretty significant for me, I kind of knew that going along being that bedside practitioner and being embedded in the community but to actually see it statistically that our town and the community we live in has the highest incidental death in that area was quite profound for me.

We engaged various stakeholders in that process to evaluate the factors that would impact those outcomes and what they found was that there were three major factors. Timely access to screening and treatment, insurance and finances and the awareness of risk and resources were were the three main areas of concern that would be impacting those outcomes.

Roadmap to begin our lung cancer screening in 2016

So we started our journey here in 2016 and we ended up securing the diagnostic capabilities I mentioned before. We had into endobronchial ultrasound, we also purchased navigational bronch in the course of 2016 to sort of round off our comprehensive abilities to receive a confirmed diagnosis locally. We also streamlined a process in developing a lung nodule clinic to allow for expedited access to our pulmonologist to diagnose and develop a plan of care. We also created a robust and educational outreach campaign. As I mentioned before, we had little to no awareness not only with the community but also with our physician groups here. We begin work on a management process for the incidental findings as I go through some of the metrics that significant figures and our incidental findings but very little management of any of those patients through the process and then finally we work to collaborate with our oncology team to streamline and expedite access for patients to treatment.

Lung Nodule Clinic Flowchart

I ended up with a multidisciplinary team it was quite apparent that we needed to have some tools so as we were doing physician relation rounds and having some discussions with primary care physicians, office managers and various others, we needed to show how the lung nodule clinic would flow.

The flowchart has listed all phone numbers and days of operations so that it’s very clear to everyone that sees this how the lung nodule clinic will flow and how the patient’s information will will also flow through the course of their treatment.

This is another chart that I created that talks about the distribution of results because you know  I’m sure you can agree that, all physicians want to know what’s going to happen with their patient once they enter into that clinic setting so that they do not lose visibility into their care. So it was very important that we were very transparent on how the results would be distributed amongst all the stakeholders.

Roadmap to expand our lung cancer screening program in 2017-2018

So here we are in 2017 and 2018 and there were three main areas of focus for us- one being the team I mentioned before, you can’t do anything without a team. Here in this case, it really takes the proverbial village pulmonology, oncology, imaging surgical services, pathology, pharmacy, marketing PRI, several others I’m sure without those being engaged in the process and you know it’s very hard to create a thriving successful program.

The central database Eon direct- we actually started with a database called notify software and however we found that it just didn’t give us the robust reporting structures that we were looking for so we subsequently utilized eon direct at that time and we’re able to have our patients in that central location through eon direct. Now we are fourth quarter 2018, have started to use Eon Direct which I find to be very user friendly. I’m very excited about the analytics has really been a game changer for us and so really excited about having that visibility in that central location at all three of those pathways funnel into so that you can see the patients through their continuum of care.

The third area that we had to do some work on is navigation and it connects the dots for the patients and the physicians. Navigation depending on your facility is quite honestly just the term you know you may have to maximize resources in your own facility or you may find that an FTE that can be supported through navigation but I think we have to use it as a verb instead of as a position because sometimes that gets difficult to operationalize.

What we did here in our facility is we did a front-end navigator her role is that she is the entry point and she uses eon direct quite often and all of the patients flow into the central database. Then she subsequently navigates them through their care through the front end of the process up to the follow-up letters.

Follow-up letters again is an another area of automation that Eon direct allows for and so that’s where we have been in our 2017-2018 years.

Marketing/Community Outreach

Now I spoke before about our marketing/community outreach campaign we did. These are just some things that I wanted to highlight here we did. an event partnered with Piedmont Community Services called Quick Kits in which we provided information about low-dose CT screenings.

We also did an event called Kick Butts at the local bowling alley and it was quite a fun fun event. We had a huge turnout for that, hospital staff came as well and we partnered with the ALA at that point in time to provide information education about smoking and lung cancer.

We’ve also done multiple lunch and learns community presentations and so forth and then we did an online health risk assessment and this one I found quite interesting because it was a six month campaign as it states here. 460 health risk assessments were completed and of those 67 appointment requests were made and 32 phone calls were actually placed as well so I found that to be quite successful we’re going to repeat that in our 2019 here as well.

We also had a targeted direct mail campaign and the way that this works is there’s an integration into our medical record system that has triggers and it sends out two targeted high-risk individuals. We have four thousand four hundred fifty-eight households with a 2183 response rate and you can see the conversion rate there, so some out-of-the-box thinking when we talk about marketing and community outreach here.

Some images of what we have been doing here I spoke of our Virginia Tech research project that’s the engaging martinsville project. We did a a lecture on that through one of our local colleges the new College Institute here. We also have been participating in senior health fairs, there’s a picture of our director of oncology at the bottom and then the farmers market uptown Summer 2018 as you can see there we have director of imaging and oncology as well. We have our director of pulmonary services engaged and an oncologist but I mentioned of this because the proverbial village I spoke of before, they also participate in all these marketing and outreach campaigns and that’s very impactful.

Here is a copy of what we placed in our local newspaper here in 2016-2017 and this speaks about lung cancer screening of course and the criteria. This is an image of our lung nodule rack cards that we use.  We strategically plan the physician relation rounds going to every primary care physician, going in front of all of our Edie physicians and so forth and we we had these strategically place and all those offices as well as the waiting room areas as well.

Roadmap to refining our lung screening program in 2019

We have three main focuses for 2019 and so what we plan to do is expand our navigation program. I spoke before we have a front-end navigator I want to close the loop on that navigation. I’ve been able to maximize some resources in our radiology department in order to close the loop there with the hopes of being able to see this patient through full disposition and with eon’s analytics, I’ll be able to have greater visibility into the patient’s continuum of care.

Also, expand community awareness and outreach and we did we did the marketing campaign throughout the the last few years and I think the thing with this is that it’s never-ending, you know, we have to stay in front of them all the time and that includes the physician, so we’re going to continue our campaigns as we move forward.

Ultimately our goal is first screening center of excellence we’re looking to be designated in quarter for 2019 so a couple of steps that have to be made before you can apply for screening center of excellence. One of those is CT accreditation specific to the chest module and we have submitted for that, our goal for that is April 2019.

Second step is the ACR designation as a lung cancer screening program once we receive the CT accreditation we can apply for that and then we can move forward through our screening center of excellence.

SCOE Requirements

In order to earn this designation, there are a couple of things that stand out to me one is the shared decision making process, second is working through best published practices and standards of care and then third is to have a lung cancer multidisciplinary team.

And then a comprehensive cessation program. We continue to work on that through the 2019 year but we had one present but I would like to expand upon that.

SCOE Designation

Reporting results have to be in a timely manner so you have to show evidence of that as well. and then finally as we mentioned designation has a lung cancer screening program through the American College of Radiology. I did a search on the Lung Cancer Alliance website and found that there’s over 600 screening centers in the United States today.

In a review of local designations for our area, 25 of those are in the closest being Lynchburg and Charlottesville to us here today and then 39 in North Carolina and I think that you know depending on you know where you’re at it’s always helpful to know where your closest screening centers of excellence are so that you can understand whether you are being competitive or and/or it sets you apart from the rest.

Sovah Health-Martinsville Metrics

In 2015, here you can see we had a an abysmal 26 low-dose CT screenings for the 2015 year unfortunately I have no visibility into the positive results from those screenings nor do I have any visibility into the incidentals for that year.

As we moved into the 2016 year, and if you recall in 2016 is when we really created closed loop on our diagnostic program and had just started working on our incidental management program as well as the nodule clinic. So for 2016 we had 27 low-dose CT screens, still no visibility into the positive results at that time and we had 250 incidental findings. But it’s important to understand this is just coded data these incidental findings I have no evidence that there was any true pathways created for any of these managed incidental findings.

In 2017, however, after our marketing campaigns and our physician rounds and so forth, you can see we had a huge increase up to 104 screenings for that year compared to the 27 that we had in 2016. Of those 104, we had 26 positive nodule result findings. So the percentage of that is 25 percent which I think it’s pretty significant and it does correlate with what we found earlier in our research project before. We find there’s a 165 incidental findings and I can say with relief that those patients were followed through the continuum of care through the program that we set forth in managing those patients and making sure that they have follow up with a primary care physician or enter into our nodule clinic.

In 2018, we had another increase in low-dose CT scan at 200 for the 2018 year, 71 of those patients had a positive nodule result finding which yielded 36 percent ratio there. We had 284 incidental findings, now, keep in mind we started our Eon direct software in quarter 3 of 2018 and so I credit a lot of those increase in incidental findings to that software because it does have the artificial intelligence capabilities and uses English characterization to pull out specific terms and it has the ability to look through multiple imaging sets. Whereas, before we can only focus on maybe CT of the chest or chest x-rays.

diagnostic treatment section

For May 2015 to 2016 I have to report that out a little bit differently just with the constraints of data reporting that I have here but EBUS and navigational Broncs we did 90 of those in that time frame. we also seen of those 90 55 of those were referred to oncology that yielded a 63% ratio.

in 2017 we did 57 in the bronchial ultrasound in that bronc cases with 39 of those being referred to oncology which was 71 percent. In 2018 we did 49 in the bronchial ultrasound navigational bronc cases with 19 of those a referral which is 39% ratio now what I want to say is I do not have visibility today into the stages what I do have is long rack information. so for the 2017 year as you can see you know we had a hundred and four low-dose CT screenings, the 27-year a lung red one was sixty one of those lung rack.

Dr. Aki Alzubaidi:

I’m going to stop because we’re getting some questions and I want to clarify a couple here. Low-dose CT scans are referring to patients who were eligible and actually had a lung cancer screen. Everybody in the colonist is 26 27 104 and 200 meant the people who are eligible and got screened at your facility and you had an increase from 26 to now and 2018 you had 200.

Correct?

When you say positive results in the NLST that meant that was a patient who had a lung cancer screen that had a nodule and that inaudible was the positive finding.

So in 2015/16 we didn’t know how many of those you know 53 or so had a positive nodule. Right? I think you can be will be hollering at you soon. In 2017 you had 25% which really matched the NLST because 25% of the patients who got a lung cancer strain in that trial had a positive finding and a positive finding was defined as having a nodule. That meant that they were lung racks two or higher right and so the other 19 you had 71 percent which is a little bit higher than a trial but if you look at what national averages are happening regionally, that’s within the range of the patients that you would expect to have a nodule.

Now and your next call in your next row you have  incidentals. Incidental is a totally separate cohort of patients who were getting a CT scan for another reason in which a nodule was detected, so, here’s what I want to just differentiate some nodules are actionable and some nodules are not actionable and what that means is that there may be nodules that would need biopsies there may be a partition or PET scans and there may be some that just need interval radiology follow-up.

In that incidentals is a totally different cohort then the ones that are in the low dose CT scan and the positive results.

Correct Tori?

Tory Shepherd:

Yes.

In 2018 our lung rads 1, we had 123 comparative to the prior year with a long one of 61. As you stated, we were able to divert or catch some of these at an earlier stage and treat them differently or run them through serial diagnostic studies a bit differently. My point being is that you know this program has really been successful here and I’m so pleased with the results that we’re already seeing and I can’t I’m excited for what the 2019 years is going to bring.

Dr. Aki Alzubaidi:

I think this is why, you know as a clinician myself and you know for joining this journey, we all do it right. We  try to catch people you know make sure the pieces of patients don’t fall to the cracks and you catch more.

Tory Shepherd:

As we go through first slide I always go back to the first one with those statistics in that 5-year survival rate and when you look at a stage one five-year survival rate versus a stage four it’s quite significant and you can see in these numbers and 2018 and I can see it in the lung red numbers that we’re making that difference here.

Dr. Aki Alzubaidi:

Absolutely

Tory Shepherd:

So I brought this slide together to try to tie everything together that we just discussed I think it’s important to have a comprehensive lung cancer screening program and  in my opinion and experience you know these are the successful elements in order to create that now there’s two important points that I want to make in regards to the lung cancer screening program you know one being is that any hospital in my opinion can develop a robust joint cancer screening program regardless of whether it is a rural setting with a community hospital or urban setting with tertiary offerings I think the key to a successful program is to understand the pathway of the patient if the loop can not be closed locally with diagnostic or treatment capabilities is important to work through partnerships and have follow-up mechanisms in place to follow the patient I think the second point I’d like to make is if you’re looking to make a business proposal things you have to look at this a bit differently from my experience as a therapist now sitting as the assistant traditionally an O R procedure would be you know an area where one would find gains and contribution margin and in the instance of lung cancer screenings you must look a little bit deeper in our facility you know Eva’s navigational bronchoscopy are performed in the o.r setting however you know the margins on these cases are going to be minimal but you have to factor these procedures and his feeders these are your theater volumes and this is contrary to how we traditionally think of theaters we think of them ct/pet scans etc but with increased volumes these can increase in contribution margin but ultimately all of the feeders lead to a larger gain and the gain in this case first and foremost is survival rates and quality of life and then you know this is made possible by serial diagnostic testing serial clinic visits and and then oncology referrals so just to sort of bring home.

What you said earlier a key you know I think if you’re looking at it from that perspective you’ll have to think of it a bit differently in my opinion and then finally screening center of excellence you know  here’s the short version of the map for me you know comprehensive lung cancer screening program leads to a CRC the module accreditation and then you can apply for your ACR designation as a lung cancer screening center and then from there you can apply for the screening center of excellence and I close with this I looked at the slide we started with about it being a journey and I like this statement here it says piece is a journey of a thousand miles it must be taken one step at a time so no matter where you enter into this, you most likely will have had quite a quite a road ahead of you but it’s is well worth the journey at the end.

Dr. Aki Alzubaidi:

So much I would like to do there’s some questions if you don’t mind going back to slide 22 and I also got a note that I didn’t introduce myself,  my name is Aki I’m an interventional pulmonologist my clinical home is National Jewish National Jewish Health and founder and co-ceo of Eon and so I have a couple of theirs questions that are coming in Tori, so let’s go through them. Questions about this DX oncology percentage and the 39%, what does that mean?

Tory Shepherd:

It’s 19 referrals of this diagnostic population that we took this EBUS navigational rocks. it’s just a reflection of the navigational population referred to oncology.

Dr. Aki Alzubaidi:

Okay,so the percentage of those that were diagnosed with cancer and went to oncology but doesn’t reflect the ones that were diagnosed from E busser nav that went to surgery though.

Tory Shepherd:  

Correct, I know you’re gonna go through some analytics but that is where we’ll be able to do that in the 2019 year.  

Dr. Aki Alzubaidi:

Gotcha and then there’s a question there’s two questions so everybody right now we’re gonna do a Q&A; session there’s two ways to ask ask questions there’s through the Q&A; module and then also through chat.

Q/A Session

Question: Does your facility do anything to ensure coverage for the screening through the patient’s insurance so how do you pre off these guys?

Answer: We have a business we work in tandem with our business office and we make sure we had meetings prior to moving forward with after CMS released guidance that we could proceed with using them after we were entered into our ACR registry and so they’re very well aware of the pre-health process and ensuring that we have that criteria in place prior to entering into a process.

Question: What is the most effective smoking cessation program you would recommend?

Answer: You know we don’t know Mariano’s of all of them quite honestly and that’s that’s a hard one for us you know getting participation into the smoking cessation program I think is more an issue and then sustaining that is is the second. I think you have to be very creative which we still have not found the answer to that one yet. we’ve done the programs through the ALA  we’ve also done some other abbreviated programs and I think it’s going to need to be tailored for the individual and their needs. you know I don’t know that we have the firm answer on that one just yet so Aki maybe you might have some other guidance.

Aki: I’ll tell you there’s a guy named Ben told who’s at MUSC Novi versus South Carolina in which there it’s a science getting people to stop smoking as a science you know in my practice I always encourage smoking cessation you know there’s many modalities to help I think that we’re still learning a lot. You know that’s that’s a tough question but I think tracking and ensuring that you offer smoking cessation at every touch point is extremely important. I think that experimenting with different techniques and deliverables in terms of what you hand to the actual patient, the different medications that you may try with them with the patient as well and just continuing to beat down how important it is to quit smoking in a way that’s positive and understanding and empathetic about how hard an addictive cigarettes are for me as a practitioner has always been the best way that’s gotten the most effective results.

So we got some hey Angie how you doing well I’m gonna call you today so Angie’s from Penn highlands and she’s awesome she’s asking if we could see the slide again about what all is involved for obtaining a center of excellence and what’s needed so Angie I’ll tell you this if you want some help with that we can definitely help you but why don’t you go to that slide again it talks about obtaining the center of excellence.

Okay I think the one that but this was the one that I would think would be the one that’s important here and so go ahead sorry let’s go on this night for Angie and then he will do is that will send you this and then there’s a few there if you know that not just the LCA but there’s other types of screening centers of excellence too that you can obtain I know the Banja Dario does one as well and I think that what we’ll do is is that we’ll get some resources together for how to become a screening center of excellence and then we’ll send that out to whoever is interested so hopefully that will help you out Angie.

Question:  How many patients in your hospital that you run this program through and once you’re estimated ROI for the program yearly?

Tory: Yeah, you know I’m still we’re still trying to work on the overall ROI. You know I’m trying to look at this a bit differently because when we do look at the 2018 the oncology referrals you know they decrease so then I have to look into the serial diagnostic studies and some of the other areas and that’s what I’m doing now in the 2019 year to determine sort of where we’re at. We do have some margin or our point of margin or the EBUS navigational rocks at least in order to break even is somewhere around 50 annually for us here and so that’s sort of what we target but again I think it’s important that you look at other sources other than your oncology referrals and I have not been able to tabulate that yet.

Question:  Do you offer a cash pay option if so do they need to meet criteria or do you allow anyone who wants screening to use the cash option?

Tori: No, you know what we work be based at one time prior to entering into the ACR registry and I believe at that time it was $300 was our it was our feet but we no longer all for that. We do accept insurance errors and we have our own local charity care and some other things and resources we can offer patients should they meet other criteria but by and large we accept only insurance.

Question: If you’re going from an ER AMR based solution to e on direct what’s the difference in analytics it seems that EMRs based solutions have hard time tracking the patient throughout the continuum for LDC to diagnosis and post diagnosis?

Tory:  Well I’ll tell you from my experience that has been the most frustrating part and and you know for us and I’m sure in multiple facilities we have layers of EMR systems and unfortunately it’s one of those things were none of them talk or interface at this point time, so to your question it is most difficult has been most difficult for us to have visibility into the patients and those that are deemed the navigators they have a significant past while navigating through all of our EMR platforms and what Eon Direct has allowed for us is to have that central location so that I don’t have to be funneling through spreadsheets and multiple other sources of information trying to capture, you know what what I’m hoping ,I’ll have in 2019 be more that visibility into the patient’s complete continuum payer once we’re able to close our loop on our navigation program.

Question:  What’s involved for the patient at this point and is this referral for all positive nodules?

Tory:  yes and yes yes. It is run by our pulmonologist our pulmonologist also has a nurse practitioner in his office as well who actually is also been a bedside nurse for a number of years as a nurse and a bedside restore therapist so he has a pretty robust program there that he runs. So our policies all of those patients and essentially the lung nodule clinic for us was designed because once we started to have those referrals going into his office what we found as they kind of went to the end of the list, Aki you may be able to relate to that from her practice and so he would find that you know he would be kind of scratching the sand once that patient gets there and saying wow I should have seen you two months ago, so we’ve developed a lung nodule clinic just to allow for that streamline pathway into that setting and right now we run that once a week as well as the numbers continue to increase that we’re going to have to come back to the drawing board reanalyze what that looks, like maybe expand upon the days so forth but it’s a it’s a pretty pretty busy place in there

Question:  For short term follow-up scans do you perform diagnostic CT scans repeat lung screening bunk screening with CPT code of seven one two five zero

Answer: First we do here we do have repeat scans here and that is at the discretion of Dr. Boyd and and what he sees in his office, his plan of care is not going to be a one size fits all for every patient. It is going to be determined upon each patient so that’s how a practice now

Aki:  Yeah you know so for me I think that this is a bigger discussion too about if there’s a long range of one or two that means that they have a baseline and then annual and those are called low-dose CT scans right, but if it’s a lung rads three or four a then like a three we’ll have a six-month follow-up and then alone that’s for a could have a PET scan or a three-month follow-up, right so the three month and the six months to me should be labeled as a low-dose CT screen follow-up, right and then you should have a low-dose annual which is the annual and a low-dose baseline in terms of the names and your procedure library. Not a lot of places do that though in addition what happens if a patient has a CT scan a regular diagnostic CT scan like a CTA that’s off cycle so if their lung rads one and the dates January one but then they come into the ED in June and they get a CTA you know what do you do do you scan them again in six months or do you go a year from when the CTA is and so there’s been multiple you know as multiple guidance on that me, as I practice what I do is that if they have another CTA I get it recorded in terms of their lung rads and then I adjust their cycle in terms of reporting one thing that we do in the application is is that it you know when we show it there’s big bars and there’s nested exams and in the big bars that’s the annual or baselines and those require a lot more data entry for submission to CMS and the nested follow-up to short-term follow-ups all they require is the type of exam and then the date performed. So you know and I’ve seen it both ways where sites are doing seven one two five zeros they’re doing regular CT scans they’re not doing reduce reduced dose CT scans and so I think that this is something that’s very complex and I probably won’t go into it into too much detail and during this webinar but I’ll tell you really really great guidance on what exams to order specifically for short term follow-ups and then even with incidental modules Tori I don’t know if you’ve seen this but you probably see a lot of variability in the protocol that’s ordered for incidental nodule follow-up to me there’s some you know there’s some good guidance documents and you know our team here we should probably put together some guidance to help our folks, in terms of exactly what should be ordered for subsequent interval radiology monitoring and then exactly what’s needed for the data entry and submission to CMS.

One thing that’s not known Toria sorry to make this long on this question but is that the LCS are will allow you to partially submit records to them and that doesn’t mean that they’re submitting to CMS on a quarterly basis those patients, you may think you’re in compliance but you may not actually be in compliance for CMS submissions of your lung cancer program and that’s another thing that we really take seriously when we do go into sites as looking at your historical back look, at how you’re actually doing things and then ensure that you’re compliant and hopefully changing behaviors so that the right tests are ordered subsequently after a nodule has been found or after a patient has been enrolled in a lung cancer screening program so sorry for the long-winded answer but it’s something that I see that there’s a lot of confusion about so let’s go on to the next question

Question: so you do education and all intervals of care not necessarily use six to eight weeks quit smoking programs how do you process pre and post-tests for example in order to receive COC credit we have smoker’s lung cancer and money but can’t get the patients to a scheduled organized meeting?

Tory: yeah we share in that same frustration III I think we touched on that a little earlier I can completely relate and I can say that we continue to struggle through that very same thing. You know we it’s important to you know understand how to sustain that and I don’t know we have not been able to to find that magic setting we just had to do it case-by-case and look at every patient and then we enter them into different programs and tailor it for them you know

Aki: I think it’s tough right I think you I think we’re all going through the same same struggles here until Question:  so how are you following incidental nodules are you sending reminder letters how do you handle that population?

Tory: Yeah, well you know what we did is we actually we had a conversation with our emergency room physicians and we sort of laid out where we were having some concerns around the incidental management particularly around the patients that did not have primary care physician as well and we had one physician that wanted to champion that and so that physician has led any follow-up conversations with those patients in regards to their incidental findings and then we enter them into our program, so we will then touch back with their primary care physician and/or enter them into our lung nodule clinic setting at that time. It’s really been helpful with them blessed with having this et physician that is just passionate about this as rest of its and he’s really taken this fun to to manage those findings herself through the emergency department

Question:  What criteria for age do you use the CMS guidelines or as NCCN or USPTA?

Tory:  we’re using and so you know 55 to 77 or 55 to 80 is what most most sites are using now based on CMS versus private insurance we just do this

Question: what’s the biggest barrier to your program our biggest barrier has been engagement with primary care seems like there hasn’t been a hardwire this family man low colon or cervical screening?

Tory: Yeah, well we see that don’t weigh in the statistics you know certainly it’s not there I’ll say at the very beginning yes that was that was an issue for us and engaging some of the primary care physicians but you know what I found and it’s something as simple as as development of the tools, because you know when you come into your presentation you’re going to have maybe 10 minutes in front of each of these physicians and it’s important to leave something that is valuable for them that they can use while you’re gone and the other thing I think is important is to have conversations with the office managers and those that work within the clinics because at times they may be able to also be an advocate for the patient to you know to receive these screenings as well

Aki:  and you know from for me I think it’s very difficult to order a lung cancer screen as a provider at a different facility in different places and tell you as you got to make it easy to actually provide the service and the order entry is very difficult sometimes and the eligibility issue in terms of primary cares or the ordering physician, ordering this test or the screen on on individuals who aren’t eligible, creates complexities too. You know I’ve had providers who have ordered it on thirty year olds trying to get them a cash pay price for a low-dose CT screen to look for other issues because they want me and so I think that managing the ordering and putting hard stops and radiology but making it as easy as possible and then engaging and educating and really hitting the streets in terms of just going to the PCP’s office is the best way. So I think that’s you know unfortunate but as you try to increase your numbers of eligible patients that can get screen you got to come you got to go out and engage the PCPs and you can’t take it negativity that they’re not doing this for eligible patients you just gotta take it as I got to educate the PCPs and make it easier for them and reduce the barrier for them to actually refer and then

Question: Tammy wants you to speak to the role of the lung nodule clinic you said this is a pulmonologist correct so I think they just wanted this a little more clarity on on what the role the what not looking to do you send everybody there do you just do three or four days or higher do you do a segment of incidentals that are higher risk what do you do?

Tory:  Well today what we do is first of all we have a conversation with the with the PCP and then we enter everyone into the nodule clinic in there Boyd then can determine you know what the plan of care may be we keep the primary care physician engaged as well I think that’s it very important back to the earlier question you had before and and with with our particular situation here we only have one pulmonologists in our community so it’s a bit easier for us if you have multiple physicians engaged you know you’ll have to look at that a bit differently but the patients we do have them all enter through the clinic for you know aggression of care

Question:  A question about group two NCCN guidelines and if you don’t do anything with them and just as a reminder NCCN group one is 55 to 70 for greater than 30 pack year history quit less than 15 years current or former smoker and then the NCCN group 2 is 50 to 74 with greater than 20 pack your smoker there that the quit duration is anytime and then they have at least one of those risk factors like family history of lung cancer personal history of smoking related cancer and things of that nature do you not screen people that are NCCN group 2 or

Tory: Yeah you know we we by and large you know do not are not at this point screening that population if it’s if we go by the CMS screening criteria you know it’s something that we need to consider and certainly we’ll have to do that as we as we move forward but you know at this point, no we we use our CMS criteria

Aki:  I think there’s a lot of evidence and studies that are going on in terms of how to either expand or reduce the screening criteria and who gets screens and then also looking at the interval and how often you do screen, right this was a large large trial that was done there’s actually a trial that was before that the il cap trial and then LST trial and so you know that the the guidelines for reimbursement were based on that and so in terms of coverage to I think that would also you know determine why most sites decide who the screen in terms of the eligibility criteria for reimbursement. So then we can talk about that offline too but I hope that answers your question

Aki: So there’s three minutes left in the hour I do want to there’s a couple questions left I try to run through those and then if you would like to stay on for I have about ten minutes afterwards to to show a demo of the actual application and then talk about four Oh which I’m excited about you know do you special society and do the scans have to be CT scans or chest x-rays which other what do you follow Fleischner or to the HTCP guidelines instead of curiosity?

Tory: Fleischner yeah

Aki: it’s usually based on CT scans you know if you had so you know this this in general, if I get an abdominal CT scan that catches the basis of the basis of the lungs or the neck CT that catches the apex of the lungs. I always reflux to or or a chest x-ray that suggests is a nodule you have to get a CT scan that’s a dedicated chest CT scan because when you decide what the interval follow-up is of that patient, you need to characterize the nodule, characterization of the nodule consists of that you know in terms of the is it a solid subsolid ground-glass the border characterization. All of those things go into the likelihood of cancer or of it being benign does it have calcifications and a benign calcification pattern, is it granulomas ,are there multiple modules or is it a solitary pulmonary nodule all of those things are gonna go into the analysis for what’s gonna happen next for the interval follow-up so whether you use Fleischner criteria or not you shouldn’t be using a chest x-ray to determine with the next interval follow-up this you shouldn’t be using it abdominal CT scan you shouldn’t be using a next CT scan you should reflex to a dedicated chest then redo your pretest probability and assign that to your to your entity that you follow for next steps and then go from there that makes sense I hope that answers your question.

Question: What do you do with patients that don’t meet screening criteria but have insurance authorization do you screen them we’ve had several really close to guidelines we’ll let through but we’ll see more than our screen having off but don’t be guys I have a very strong feeling about this but Tory you answer.

Tory:  I don’t know that I have any experience with that at this point.

Aki: I have experience with this one and I’ll tell you that anything that can happen will happen. Right? and if you screen people that are outside of the eligibility criteria, you can likely find an incidental finding.

Now that incidental finding will make you go down a pathway of having to if it’s an if its indeterminate nodule you’ll have to do something. The likelihood of that patient having cancer is lower than the patient in the eligibility population and you may be exposing that patient to unneeded comorbidities and complications that would not provide the mortality or morbidity benefit within the eligible population. I think that it’s not correct to screen people that are outside of the eligibility population from either CMS private or the US Preventive Services or NCCN and that’s my personal opinion. Some people do it with other high risk groups and I say that’s research. I don’t think if that’s not an evidence-based practice, best research to me and should be done under a research trial.

You guys can continue to ask questions about the application if you want.

Tory, thank you so so much! This has been excellent

Tory: Yes absolutely!

I’m just thankful to be here and thankful to take you guys and the service you provide us as well.