The Association of Health Care System Resources With Lung Cancer Screening Implementation: A Cohort Study

Jennifer A Lewis, Lauren R Samuels, Jason Denton, Michael E Matheny, Amelia Maiga, Christopher G Slatore, Eric Grogan, Jane Kim, Robert H Sherrier, Robert S Dittus, Pierre P Massion, Laura Keohane, Christianne L Roumie, Sayeh Nikpay, Jennifer A Lewis, Lauren R Samuels, Jason Denton, Michael E Matheny, Amelia Maiga, Christopher G Slatore, Eric Grogan, Jane Kim, Robert H Sherrier, Robert S Dittus, Pierre P Massion, Laura Keohane, Christianne L Roumie, Sayeh Nikpay

Abstract

Background: The Veterans Health Administration issued policy for lung cancer screening resources at eight Veterans Affairs Medical Centers (VAMCs) in a demonstration project (DP) from 2013 through 2015.

Research question: Do policies that provide resources increase lung cancer screening rates?

Study design and methods: Data from eight DP VAMCs (DP group) and 20 comparable VAMCs (comparison group) were divided into before DP (January 2011-June 2013), DP (July 2013-June 2015), and after DP (July 2015-December 2018) periods. Coprimary outcomes were unique veterans screened per 1,000 eligible per month and those with 1-year (9-15 months) follow-up screening. Eligible veterans were estimated using yearly counts and the percentage of those with eligible smoking histories. Controlled interrupted time series and difference-in-differences analyses were performed.

Results: Of 27,746 veterans screened, the median age was 66.5 years and most were White (77.7%), male (95.6%), and urban dwelling (67.3%). During the DP, the average rate of unique veterans screened at DP VAMCs was 17.7 per 1,000 eligible per month, compared with 0.3 at comparison VAMCs. Adjusted analyses found a higher rate increase at DP VAMCs by 0.93 screening per 1,000 eligible per month (95% CI, 0.25-1.61) during this time, with an average facility-level difference of 17.4 screenings per 1,000 eligible per month (95% CI, 12.6-22.3). Veterans with 1-year follow-up screening also increased more rapidly at DP VAMCs during the DP, by 0.39 screening per 1,000 eligible per month (95% CI, 0.18-0.60), for an average facility-level difference of 7.2 more screenings per 1,000 eligible per month (95% CI, 5.2-9.2). Gains were not maintained after the DP.

Interpretation: In this cohort, provision of resources for lung cancer screening implementation was associated with an increase in veterans screened and those with 1-year follow-up screening. Screening gains associated with the DP were not maintained.

Keywords: early detection of cancer; implementation; lung cancer screening; lung neoplasm; policy; utilization.

Published by Elsevier Inc.

Figures

Figure 1
Figure 1
Cohort flow chart. VAMC = Veterans Affairs Medical Center.
Figure 2
Figure 2
Graphs showing interrupted time series analyses. A, Facility-level average number of unique veterans screened per 1,000 eligible veterans per month at Veterans Affairs Medical Centers (VAMCs) with complexity level 1a. B, Facility-level average number of unique veterans screened with eventual 1-year follow-up (9-15 months) per 1,000 eligible veterans per month at VAMCs with complexity level 1a. C, Facility-level average number of unique veterans screened per 1,000 eligible veterans per month at VAMCs with complexity level 1b. D, Facility-level average number of unique veterans screened with eventual 1-year follow-up (9-15 months) per 1,000 eligible veterans per month at VAMCs with complexity level 1b. aDemonstration Project refers to the Veterans Affairs Lung Cancer Screening Demonstration Project that took place from 2013 through 2015 at these eight VAMCs: Ann Arbor, Charleston, Cincinnati, Durham, Minneapolis, New York Harbor, Portland, and San Francisco. Comparison VAMCs refer to comparison VAMCs with complexity level 1a that applied but were not selected to participate in the Demonstration Project. bDefined as a subsequent scan 9 to 15 months after the initial scan.
Figure 3
Figure 3
Graphs showing interrupted time series sensitivity analyses. A, Facility-level average number of unique veterans screened per 1,000 eligible veterans per month at Veterans Affairs Medical Centers (VAMCs) with complexity level 1a. B, Facility-level average number of unique veterans screened with eventual 1-year follow-up (9-15 months) per 1,000 eligible veterans per month at VAMCs with complexity level 1a. C, Facility-level average number of unique veterans screened per 1,000 eligible veterans per month at VAMCs with complexity level 1b. D, Facility-level average number of unique veterans screened with eventual 1-year follow-up (9-15 months) per 1,000 eligible veterans per month at VAMCs with complexity level 1b. aDemonstration Project refers to the Veterans Affairs Lung Cancer Screening Demonstration Project that took place from 2013 through 2015 at these eight VAMCs: Ann Arbor, Charleston, Cincinnati, Durham, Minneapolis, New York Harbor, Portland, and San Francisco. Comparison VAMCs refer to comparison VAMCs with complexity level 1a that applied but were not selected to participate in the Demonstration Project. bDefined as a subsequent scan 9 to 15 months after the initial scan.

References

    1. National Lung Screening Trial Research Team. Aberle D.R., Adams A.M., et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395–409.
    1. de Koning H.J., van der Aalst C.M., de Jong P.A., et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382(6):503–513.
    1. Moyer V.A., United States Preventive Services Task Force Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330–338.
    1. Wender R., Fontham E.T., Barrera E., Jr., et al. American Cancer Society lung cancer screening guidelines. CA Cancer J Clin. 2013;63(2):107–117.
    1. Wood DE, Kazerooni EA, et al. NCCN Clinical Practices Guidelines in Oncology (NCCN Guidelines) for lung cancer screening version 1.2021. 2021. National Comprehensive Cancer Network website. Accessed January 3, 2021.
    1. Jaklitsch M.T., Jacobson F.L., Austin J.H., et al. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. J Thorac Cardiovasc Surg. 2012;144(1):33–38.
    1. American Lung Association Providing guidance on lung cancer screening to patients and physicians. American Lung Association website.
    1. Mazzone P.J., Silvestri G.A., Patel S., et al. Screening for lung cancer: CHEST guideline and expert panel report. Chest. 2018;153(4):954–985.
    1. National Center for Health Promotion and Disease Prevention, U.S. Department of Veterans Affairs. Get recommended screening tests and immunizations for women. National Center for Health Promotion and Disease Prevention, U.S. Department of Veterans Affairs website.
    1. Veterans Health Administration. U.S. Department of Veterans Affairs U.S. Veterans Health Administration, Department of Veterans Affairs, website.
    1. Lewis J.A., Samuels L.R., Denton J., et al. National lung cancer screening utilization trends in the Veterans Health Administration. JNCI Cancer Spectr. 2020;4(5):pkaa053.
    1. Jemal A., Fedewa S.A. Lung cancer screening with low-dose computed tomography in the United States 2010 to 2015. JAMA Oncol. 2017;3(9):1278–1281.
    1. Kinsinger L.S., Atkins D., Provenzale D., Anderson C., Petzel R. Implementation of a new screening recommendation in health care: the Veterans Health Administration’s approach to lung cancer screening. Ann Intern Med. 2014;161(8):597–598.
    1. Jackson GL, King HA, McNeil RB, et al. Evaluation of the VA Lung Cancer Screening Clinical Demonstration Project—report submitted to the Veterans Affairs Office of the Under Secretary for Health. 2016. March 2016.
    1. Kinsinger L.S., Anderson C., Kim J., et al. Implementation of lung cancer screening in the Veterans Health Administration. JAMA Intern Med. 2017;177(3):399–406.
    1. Schoenhard W. Memorandum: Lung Cancer Screening Clinical Demonstration Project. In: Department of Veterans Affairs; 2012.
    1. Daw J.R., Hatfield L.A. Matching and regression to the mean in difference-in-differences analysis. Health Serv Res. 2018;53(6):4138–4156.
    1. U.S. Department of Veterans Affairs. Veterans Health Administration. Summary of VHA facility complexity model. Veterans Health Administration website.
    1. Lewis J.A., Spalluto L.B., Henschke C.I., et al. Protocol to evaluate an enterprise-wide initiative to increase access to lung cancer screening in the Veterans Health Administration. Clin Imaging. 2020;73:151–161.
    1. Cattaneo S.M., 2nd, Meisenberg B.R., Geronimo M.C.M., Bhandari B., Maxted J.W., Brady-Copertino C.J. Lung cancer screening in the community setting. Ann Thorac Surg. 2018;105(6):1627–1632.
    1. Bhandari S., Tripathi P., Pham D., Pinkston C., Kloecker G. Performance of community-based lung cancer screening program in a Histoplasma endemic region. Lung Cancer. 2019;136:102–104.
    1. McKee B.J., McKee A.B., Flacke S., Lamb C.R., Hesketh P.J., Wald C. Initial experience with a free, high-volume, low-dose CT lung cancer screening program. J Am Coll Radiol. 2013;10(8):586–592.
    1. Walker B.L., Williamson C., Regis S.M., et al. Surgical outcomes in a large, clinical, low-dose computed tomographic lung cancer screening program. Ann Thorac Surg. 2015;100(4):1218–1223.
    1. Henschke C.I., Yip R., Shaham D., et al. The regimen of computed tomography screening for lung cancer: lessons learned over 25 years from the International Early Lung Cancer Action Program. J Thorac Imaging. 2021;36(1):6–23.
    1. Raghavan D., Wheeler M., Doege D., et al. Initial results from mobile low-dose computerized tomographic lung cancer screening unit: improved outcomes for underserved populations. Oncologist. 2020;25(5):e777–e781.
    1. Kaminetzky M., Milch H.S., Shmukler A., et al. Effectiveness of Lung-RADS in reducing false-positive results in a diverse, underserved, urban lung cancer screening cohort. J Am Coll Radiol. 2019;16(4 pt A):419–426.
    1. Department of Veterans Affairs. Memorandum: lung cancer screening with low dose computed tomography (VAIQ: 7845332). November 27, 2017.
    1. U.S. Department of Veterans Affairs. National Oncology Program Office, National Precision Oncology Program. US Department of Veterans Affairs website.
    1. VA and GO2 Foundation for Lung Cancer partner to improve outcomes for veterans at risk for lung cancer [press release]. GO2 Foundation for Lung Cancer website.
    1. Centers for Medicare and Medicaid Services. U.S. Department of Health and Human Services Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N). Centers for Medicare and Medicaid Services website.

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