Improving the implementation of lung cancer screening guidelines at UNC DANIEL S. REULAND, MD, MPH IHQI SEED GRANT SYMPOSIUM MAY 24, 2016
Background • Lung cancer is the leading cause of cancer mortality in US • Lung cancer screening with low dose computed tomography (LDCT) can reduce mortality • Screening can also cause harms • Annual screening recommended for high risk smokers • Shared decision-making recommended (required by CMS)
Project Aims – Improve UNC’s capability to systematically • Identify potentially eligible population • Age 55-80 years, 30+ pack years, currently smoke or quit < 15 years ago • Alert primary care providers to potentially eligible patients • Automated clinical reminder • Support high quality informed/ shared decision making processes • Decision aid, shared decision making documentation, billing • Interpret and report CT images in a standard way • Lung-RADS is a nodule classification system designed to standardize reporting and follow-up
Dr. Ratner’s Experience • Recently saw a 62 year old patient with chronic medical problems not seen for over a year • Dr. Ratner was alerted to consider offering lung cancer screening • She deferred alert until the next visit when there was more time • Next visit: shared decision making, documented & billed for counseling • Patient chose to get screened, CT ordered & completed • Lung-RADS 2 (benign appearance), recommendation to rescreen in one year “The report was very clear. I think the patient was very satisfied, and the whole process was very easy for me.”
Getting there wasn’t easy
Screening process Patient Primary Care Radiology Pulmonary/ step Team subspecialty Potentially eligible patients identified Full smoking history obtained “Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)
Screening process Patient Primary Care Radiology Pulmonary/ step Team subspecialty Potentially eligible patients identified Full smoking history obtained “Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)
Screening process Patient Primary Care Radiology Pulmonary/ step Team subspecialty Potentially eligible patients identified Full smoking history obtained “Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)
Gap: No systematic way to identify potentially eligible patients Screening eligibility criteria 1. Ages 55-80 years 2. 30 or more pack-years (packs per day x years) of smoking* 3. Current smoker or, if former smoker, quit within past 15 years* * not systematically collected or recorded in discrete fields in EHR
Systematic recording of smoking history Tamrah Parker, MSN, RN, FNP-C – Clinic Nurse Manager
Collection of Smoking History
Improving collection of complete smoking history Tested nurse protocol Nurse training kickoff Individual feedback Weekly progress updates Weekly w inners’ board Rewards for meeting goals Flagging the appointment schedule (reminder)
Appointment Schedule Flagging
Weekly completion rate for smoking histories for 55-80 year old patients seen in clinic Winners’ Board Added Flagging Kickoff Mtg. Flagging Flagging Other BPA Flagging Nurse Reward Stopped Chart Flagging Begins Stopped Resumed Activated Lunch Resumed 90% 80% 70% 60% 50% 40% 30% 20% 10% 96 109 95 88 81 72 60 88 66 31 6 39 65 32 34 46 47 32 40 37 48 34 45 42 42 28 36 42 33 0% Complete� Smoking� History Goal Cumulatively, 58% of current and former smokers age 55-80 seen since project start have had a complete smoking history assessed (894/1552)
Gap: No system for having providers systematically consider (or offer) screening for potentially eligible patients
Screening process Patient Primary Care Radiology Pulmonary/ step Team subspecialty Potentially eligible patients identified Full smoking history obtained “Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)
Complete smoking histories trigger a clinical reminder (BPA)
Training & Testing the Clinical Reminder (BPA) Training kickoff session at division meeting Peer to peer training (academic detailing) BPA active in Epic “playground” training environment
How did we do? Elizabeth Greig, MD – Assistant Medical Director
Clinical reminder (BPA) utilization, before and after peer training (n=512) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 11% 22% 19% 71% 70% 8% 0% Completed� Reminder Deferred� Reminder No� Action No� Training/Pre-Training Post-Training
Screening process Patient Primary Care Radiology Pulmonary/ step Team subspecialty Potentially eligible patients identified Full smoking history obtained “Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)
Gap: No systematic approach to providing shared decision making BENEFIT HARMS • Mortality reduction • False positives leading to (3-5 deaths averted invasive procedures (20-25 per 1000 individuals per 1000 individuals screened) screened annually) • Overdiagnosis • Radiation (small) • Anxiety • Costs
Shared Decision Making A collaborative process between patient and provider to make healthcare decisions together taking into account evidence, as well as patient values and preferences* CMS requires a shared decision making visit (using a decision aid) before it will pay for lung cancer screening *Informed Medical Decisions Foundation, 2016
Enhancing lung cancer screening shared decision-making M. Patricia Rivera, MD, FCCP – Professor of Medicine, Pulmonary Diseases and Critical Care Medicine
Enhancing Shared Decision-Making Provided infrastructure to support shared decision making and tobacco counseling (including documentation) Linked brief decision aid to clinical reminder Resident training Guidance regarding billing for shared decision making visit
Screening process Patient Primary Care Radiology Pulmonary/ step Team subspecialty Potentially eligible patients identified Full smoking history obtained “Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)
Gap: No standardized way to interpret and report CT images
Subspecialty Working Group for Lung Cancer Screening Joined QI project with existing group piloting a research registry of lung cancer screening Agreed on Lung-RADS based classification system Worked with thoracic radiology to understand workflow and develop a dictation template
Screening CTs with Lung-RADS documented (average 23 CTs/quarter, increasing) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0% 40% 92% 95% 93% 0% Q1� 2015� (11) Q2� 2015� (14) Q3� 2015� (15) Q4� 2015� (26) Q1� 2016� (63) Q2� 2016� (14) %� With� Lung-RADS
Screening CT findings at UNC Lung-RADS Category % of CT Follow-Up Plan scans 1 & 2 (benign appearance) 87% repeat in 1 year 3 (probably benign) 4% repeat in 6 months 4 (suspicious) 9% referral to MTOP n=103 screening CTs
Lung-RADS streamlines follow up planning and care Elizabeth Greig, MD – Assistant Medical Director
Spread Plan Assess place among institutional priorities Refine population-level management plan for abnormal CTs (nodules) Health maintenance build in EPIC@UNC Train nurses & providers Turn on clinical reminder by practice PDSA cycles within practices Spread across PCIC with common metrics
Lessons Learned Importance of crossing the continuum of care Need to integrate informatics and best practices High quality lung cancer screening program implementation limited by competing demands (payment model)
Acknowledgements UNC Internal Medicine Clinic UNC Health Care Practice Quality and Innovation (PQI) Primary Care Improvement Collaborative (PCIC) R21 Registry Group
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