Background

Lung cancer screening (LCS) implementation is complicated by the Centers for Medicare and Medicaid Services reimbursement requirements of shared decision-making and tobacco cessation counseling. LCS programs can utilize different structures to meet these requirements, but the impact of programmatic structure on provider behavior and screening outcomes is poorly described.

Patients and Methods

In a retrospective chart review of 624 patients in a hybrid structure, academic LCS program, we compared characteristics and outcomes of primary care provider (PCP)- and specialist-screened patients. We also assessed the impact of the availability of an LCS specialty clinic and best practice advisory (BPA) on PCP ordering patterns using electronic medical record generated reports.

Results

During the study period of July 1, 2014 through June 30, 2018, 48% of patients were specialist-screened and 52% were PCP-screened; there were no clinically relevant differences in patient characteristics or screening outcomes between these populations. PCPs demonstrate distinct practice patterns when offered the choice of specialist-driven or PCP-driven screening. Increased exposure to a LCS BPA is associated with increased PCP screening orders. The addition of a nurse navigator into the LCS program increased documentation of shared decision-making and tobacco cessation counseling to > 95% and virtually eliminated screening of ineligible patients.

Conclusions

Systematic interventions including a BPA and nurse navigator are associated with increased screening and improved program quality, as evidenced by reduced screening of ineligible patients, increased lung cancer risk of the screened population, and improved compliance with LCS guidelines. Individual PCPs demonstrate clear preferences regarding LCS that should be considered in program design.

中文翻译：

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混合肺癌筛查模型对患者结果和提供者行为的影响。

背景

由于医疗保险和医疗补助服务中心对共同决策和戒烟咨询的报销要求，肺癌筛查 (LCS) 的实施变得复杂。LCS 项目可以利用不同的结构来满足这些要求，但是项目结构对提供者行为和筛选结果的影响却没有得到很好的描述。

患者和方法

在对混合结构、学术 LCS 计划中的 624 名患者进行的回顾性图表审查中，我们比较了初级保健提供者 (PCP) 和专科筛查患者的特征和结果。我们还使用电子病历生成的报告评估了 LCS 专科诊所和最佳实践咨询 (BPA) 的可用性对 PCP 订购模式的影响。

结果

在2014年7月1日至2018年6月30日的研究期间，48%的患者接受了专科筛查，52%的患者接受了PCP筛查；这些人群之间的患者特征或筛查结果没有临床相关差异。当提供专家驱动或 PCP 驱动的筛选选择时，PCP 表现出不同的实践模式。LCS BPA 暴露的增加与 PCP 筛查订单的增加有关。在 LCS 计划中增加了一名护士导航员，将共享决策和戒烟咨询的记录增加到了 95% 以上，并且几乎消除了对不合格患者的筛查。

结论

包括 BPA 和护士导航在内的系统性干预措施与增加筛查和提高计划质量有关，这可以通过减少不合格患者的筛查、增加筛查人群的肺癌风险以及提高对 LCS 指南的依从性来证明。个人 PCP 表现出对 LCS 的明确偏好，应在计划设计中予以考虑。