Improving the implementation of lung cancer screening guidelines at - - PowerPoint PPT Presentation

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Improving the implementation of lung cancer screening guidelines at - - PowerPoint PPT Presentation

May 18, 2023 39 likes •382 views

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

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Improving the implementation

  • f lung cancer screening

guidelines at UNC

DANIEL S. REULAND, MD, MPH IHQI SEED GRANT SYMPOSIUM MAY 24, 2016

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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)

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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

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  • 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.”

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Getting there wasn’t easy

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Screening process step Patient Primary Care Team Radiology Pulmonary/ subspecialty Potentially eligible patients identified Full smoking history

  • btained

“Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)

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Screening process step Patient Primary Care Team Radiology Pulmonary/ subspecialty Potentially eligible patients identified Full smoking history

  • btained

“Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)

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Screening process step Patient Primary Care Team Radiology Pulmonary/ subspecialty Potentially eligible patients identified Full smoking history

  • btained

“Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)

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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

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Systematic recording of smoking history

Tamrah Parker, MSN, RN, FNP-C – Clinic Nurse Manager

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Collection of Smoking History

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Improving collection of complete smoking history

Tested nurse protocol Nurse training kickoff Individual feedback Weekly progress updates Weekly winners’ board Rewards for meeting goals Flagging the appointment schedule (reminder)

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Appointment Schedule Flagging

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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% 10% 20% 30% 40% 50% 60% 70% 80% 90% Complete Smoking History Goal

Weekly completion rate for smoking histories for 55-80 year old patients seen in clinic

Kickoff Mtg. Chart Flagging Begins Winners’ Board Added Flagging Stopped Flagging Resumed Other BPA Activated Nurse Reward Lunch Flagging Stopped Flagging Resumed

Cumulatively, 58% of current and former smokers age 55-80 seen since project start have had a complete smoking history assessed (894/1552)

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Gap: No system for having providers systematically consider (or offer) screening for potentially eligible patients

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Screening process step Patient Primary Care Team Radiology Pulmonary/ subspecialty Potentially eligible patients identified Full smoking history

  • btained

“Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)

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Complete smoking histories trigger a clinical reminder (BPA)

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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

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How did we do?

Elizabeth Greig, MD – Assistant Medical Director

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Clinical reminder (BPA) utilization, before and after peer training (n=512)

11% 19% 71% 22% 8% 70%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Completed Reminder Deferred Reminder No Action

No Training/Pre-Training Post-Training

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Screening process step Patient Primary Care Team Radiology Pulmonary/ subspecialty Potentially eligible patients identified Full smoking history

  • btained

“Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)

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Gap: No systematic approach to providing shared decision making

BENEFIT

  • Mortality reduction

(3-5 deaths averted per 1000 individuals screened)

HARMS

  • False positives leading to

invasive procedures (20-25 per 1000 individuals screened annually)

  • Overdiagnosis
  • Radiation (small)
  • Anxiety
  • Costs
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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

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Enhancing lung cancer screening shared decision-making

  • M. Patricia Rivera, MD, FCCP – Professor of Medicine, Pulmonary Diseases and Critical Care Medicine
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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
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Screening process step Patient Primary Care Team Radiology Pulmonary/ subspecialty Potentially eligible patients identified Full smoking history

  • btained

“Clinical eligibility” assessed “Preference eligibility” assessed (shared decision making) Chest CT ordered CT Scan completed, interpreted & reported Follow-up care (results dependent)

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Gap: No standardized way to interpret and report CT images

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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

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Screening CTs with Lung-RADS documented

(average 23 CTs/quarter, increasing)

0% 0% 40% 92% 95% 93%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Q1 2015 (11) Q2 2015 (14) Q3 2015 (15) Q4 2015 (26) Q1 2016 (63) Q2 2016 (14) % With Lung-RADS

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Screening CT findings at UNC

Lung-RADS Category % of CT scans Follow-Up Plan

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

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Lung-RADS streamlines follow up planning and care

Elizabeth Greig, MD – Assistant Medical Director

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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

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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)

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Acknowledgements

UNC Internal Medicine Clinic UNC Health Care Practice Quality and Innovation (PQI) Primary Care Improvement Collaborative (PCIC) R21 Registry Group