Outreach and Education of Providers

Most programs have a process of education and outreach to inform the provider community about eligibility criteria, the process for ordering an LCS study, or the referral process to the LCS program including who will subsequently manage the shared decision making discussion, CT scan, and subsequent management and follow up of exam findings.

JM: Education can take many forms: grand rounds presentations, visits to offices, newsletters, web overviews and decision aids, on-hold messages, health fairs, and journal articles are examples. Education efforts should be multifaceted and repeated over time, particularly early in a program’s existence. The primary care champion for the program can provide guidance about the most effective means of communication with the primary care group. Automated reminder systems can be built into many EHRs that can serve to educate the ordering provider.


AM: We began by assisting primary care through an education campaign consisting of face-to-face meetings with PowerPoint presentations to inform practitioners of the characteristics of patients who are at high-risk for lung cancer. During these visits, we provided office materials that could be used by medical assistants to identify the high-risk population as well as shared decision-making tools to assist in performing these conversations.


PM/RSW/KS/CCT: Our program focused on educating the community of providers who will refer patients for screening. Education can take many forms: grand rounds presentations, visits to offices, newsletters, web overviews and decision aids, on-hold messages, health fairs, and journal articles are examples. Education efforts should be multifaceted and repeated over time, particularly early in a program’s existence. The primary care champion for the program can provide guidance about the most effective means of communication with the primary care group. Similar education and marketing efforts targeting potentially eligible patient populations should also be considered. Patient education tools in the form of pamphlets, call-lines, internet resources, and letters can be considered in conjunction with marketing experts.


CF: The screening program educates PCPs regularly regarding criteria for eligibility, components of shared decision making and smoking cessation counseling. This is done twice a year at regular group meetings which most of our PCPs attend and also plan for the program director to do site visits to individual PCP offices to provided education. We have a brochure that we provide to PCP offices for patients as well.

ABK/CCT:

  • Provide information and tools to address physician concerns.
  • Educate clinicians on time involved with shared decision-making discussion.
  • Provide decision aid.
  • Review screening results in NLST and your program.
  • Provide false positive rate in your program with ACR Lung-RADS™ (12 percent at baseline decreases to 5-6 percent on additional screening rounds).36
  • Inform clinicians of rate of invasive intervention for benign disease.
  • Review potential for over-diagnosis based on Patz study 3 percent when BAC excluded.20
  • Describe referring MD involvement to follow-up for incidental findings.
  • Discuss radiation exposure for follow-up imaging.
  • Review cost potential for follow-up tests and interventions.
  • Address AAFP lack of endorsement for screening.
  • Assist PCPs through EHR and office work-flow to identify high-risk population.
  • Prepare primary care to conduct shared decision-making discussion.
  • Review evidence of screening results across disease sites.
  • Show broad society support for LCS.

CF:

  • Education (as noted above under 3F), including site visits to offices to review purpose and process and answer questions.
  • Examples of shared decision making tools provided, as well as links to online tools.
  • Educational video. One of our PCP’s made a video that patients can watch and then discuss with their provider.
  • PCPs encouraged to contact program directly with any questions or concerns.
  • Emphasize LCS program commitment to make sure ordering provider aware of all abnormal results that need followup even if not a positive lung cancer screen.

ABK/CCT:

  • Screening program personal visits PCP, pulmonary, cardiology, and ob/gyn practices.
  • Grand rounds, noon conferences, and medical leadership presentations.
  • Regular bulletins with program quality metrics and latest updates to referring physician practices.
  • Emphasize additional health benefit for increased smoking cessation and reduced relapse rates for those in an LCS program.
  • Having a resource or “go to” person that is readily responsive for PCP support.
  • Hospital newsletter write-up.
  • Provide informational materials for exam rooms and handing out, including emergency rooms, urgent care sites, radiology, PFT lab, pulmonary and cardiac rehab, inpatient rooms (see Resource Section).
  • PCP representative on LCS steering committee and lung nodule team.

DKM:

  • CME credited video on LCS e.g., MorningCME.com (use search term “lung cancer screening”).21
  • Hospital-wide e-mail on pertinent topics each month including LCS.

DTC:

  • Physician outreach via grand round presentations for various specialties, visits to primary care sites.
  • Website and postings on our health system’s provider intranet.
  • 0.5 credit CME educational video that we have distributed to care providers.

RSW/KS:

  • Grand rounds presentations at BMC and affiliated community health centers.
  • LCS Program website. The website includes general information, patient education materials, and a healthcare provider information page with links to background reading (e.g., original research articles, LCS guidelines), instructions for ordering LCS, local resources, and contact number for further information.
  • EPIC best practice alert to remind healthcare providers when a patient is eligible for LCS, with associated instructions for how to order LCS (e.g., reminder about eligibility criteria, shared decision-making).

CF:

  • Working with administration to generate a list of potentially eligible patients from our EMR that will be provided to PCP’s with emphasis on the importance of determining true eligibility and engaging in a shared decision making discussion regarding screening with appropriate patients. This list can also be used to identify patients that need smoking cessation counseling, regardless of risk for lung cancer.
  • Making sure PCP’s aware of reimbursement for shared decision making and appropriate billing codes.

Key elements for a five-minute discussion between provider and patient regarding LCS

Healthcare experts recommend LCS for individuals at high-risk for developing lung cancer. The goal of LCS is to detect lung cancer early to save lives. Without LCS, lung cancer is usually not found until a person develops symptom, and at that time, it is more difficult to treat. LCS is performed using a lower radiation version of a chest CT scan, taking an image of your lungs and surrounding structures. This is a 10-minute test that is performed as an outpatient.

Eligibility criteria

  • As a Medicare or Medicaid patient, you are eligible for LCS if you are age 55 to 77, have smoked the equivalent of one pack of cigarettes per day for at least 30 years, and are a current smoker or quit smoking within the past 15 years.
  • As a private health insurance patient, you are eligible for LCS if you are age 55 to 80, have smoked the equivalent of one pack of cigarettes per day for at least 30 years, and are current smoker or quit smoking within the past 15 years.
  • It is important that you have no signs or symptoms of lung cancer including: persistent cough, worsening of chronic cough, coughing up blood, constant chest pain, persistent hoarseness or unintentional weight loss of greater than 10 percent of baseline weight. If you have any of these symptoms, then a different type of diagnostic evaluation is required.

Potential benefits

  • The major benefit of LCS is preventing death from lung cancer.
  • A large national study called the National Lung Screening Trial has shown that LCS with a low-dose CT scan can decrease lung cancer deaths by 20 percent in high-risk individuals. In other words, CT screening resulted in three fewer lung cancer deaths for every 1,000 individuals screened.
  • CT screening for lung cancer is at least as effective in preventing lung cancer deaths in high-risk individuals as mammography is in preventing breast cancer deaths and colonoscopy is in preventing colon cancer deaths.
  • If you are concerned about the possibility of having lung cancer, a normal screening CT scan can be reassuring.

Potential harms

There are several potential harms to a screening that you should consider:

Radiation risk:

  • The screening CT scan will expose you to a low level of radiation, equivalent to six months of background radiation exposure or 50 coast-to-coast round-trip flights in a commercial airplane.
  • This is considered a very low risk.

Anxiety risk:

  • One in 10 patients may have an abnormality other than a lung nodule(s) found on the scan that is not causing any symptoms but may require evaluation.
  • One in four patients may have a lung nodule or “spot” found on screening CT. The number of false positive findings or “false alarms” outnumber cancers by 25 to one.

Complication risk:

  • Sometimes a finding on the screening CT leads to the need for additional testing such as a biopsy or surgery that can cause harm in individuals that do not have cancer.
  • The risk for a major complication from invasive procedures is three for every 1,000 individuals undergoing such additional testing.

Overdiagnosis risk:

  • There is a possibility that a lung cancer could be diagnosed by screening that would never cause a problem because it is very slow growing.
  • One in 10 lung cancers found by CT screening will never cause a problem for the patient.

Cost

As an eligible Medicare or Medicaid patient, the screening CT scan will not cost you anything out of pocket.

As an eligible private health insurance patient, the screening CT scan will not cost you anything out of pocket nor be charged to your deductible.

Screening Modality

  • The 20 percent decrease in lung cancer deaths found in the large national study was through screening with low-dose CT scan.
  • A separate large national study showed that routine chest x-ray is of no benefit for LCS.

Patient Commitment

  • Like mammography, LCS is not a one-time test. You should be willing to undergo yearly screening as long as you continue to meet the eligibility requirements.
  • In addition, you should be willing to undergo surgery to treat an early stage lung cancer detected by screening.

Smoking Cessation

  • Smoking cessation remains the most effective way to prevent lung cancer as a current smoker, we want to help you quit smoking for good.
  • CT screening for lung cancer is most effective in decreasing your risk of death from lung cancer when combined with smoking cessation.

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