Program Implementation Q&A

AM: Primary care, CT schedulers, program navigators, CT technologists, radiologists, pulmonologists, thoracic surgeons, radiation oncologists, medical oncologists and smoking cessation counselors.


MD: LCS is multidisciplinary and requires substantial data management and patient tracking. The key person is a LCS coordinator or navigator. This person will have substantial interaction with patients and providers, should be knowledgeable in lung cancer and its evaluation, and be skilled in managing the data and patient tracking. Most program coordinators are nurses, often an advanced practice nurse, and therefore able to conduct shared decision-making visits.

Radiology is also key. Many successful programs have a subset of radiologists develop experience in interpreting screening studies using a structured interpretation such as Lung-RADS. Because most of the findings are small nodules, pulmonary and thoracic surgery services are also important to a successful program. Other specialists may develop a particular interest in early detection, such as medical and radiation oncology, and become local leaders for a LCS program.


DTC: Our Task Force consists of representatives from thoracic surgery, medical oncology, pulmonary medicine, radiology, radiation oncology, primary care, smoking cessation counselor, radiology chief administrative officer, radiology physicist, radiology manager of medical diagnostics informatics, and a representative from hospital IT (electronic health record).


CCT: Our program includes diagnostic and interventional radiology, pulmonary, radiation oncology, oncology, a nurse practitioner in pulmonary, thoracic surgery, pathology, and a nurse navigator. We work closely with primary care and attend their leadership meetings for input regarding the program. CT schedulers are vital in verifying screening criteria with each order. It is crucial to assisting us with developing notification systems and alerting our nurse navigator for nodule tracking and patient appointments. Medical residents work with our research and quality improvement section and at times attend multidisciplinary team meetings. Primary care providers and clinical providers of patients being reviewed are also invited. The nurse navigator works to ensure care coordination throughout the program, performs tracking and manages our program database, performs education to providers throughout the system, conducts outreach to the community, performs smoking cessation counseling and survivorship visits.


CF: Core personnel include our program navigator who reviews all referred individuals for appropriateness of screening, schedules exams, collects results and brings to lung cancer program physician for review, contacts patients and PCP’s by phone and mail regarding results, schedules necessary follow-ups including Pulmonary consults for positive scans and communicates directly with PCP offices regarding patient results and compliance with screening. In addition to the navigator, the program director and program manager provide guidance and education to PCP offices.

AM: It was helpful to demonstrate radiology downstream financial events, appeal to desire for organizational leadership as a result of involvement in this clinically impactful multidisciplinary program, and appeal to desire for professional advancement through content expertise in this emerging new field within radiology.


MD: There is evidence that lung cancer screening is effective at preventing deaths from lung cancer, something all medical providers can support, and radiology practices are often committed to other forms of cancer screening, such as mammography. Using the number needed to screen to prevent a cancer death, lung cancer screening may be the most effective form of cancer screening, more effective than mammography. Every major organization involved in lung cancer recommends lung cancer screening. Many programs allow the screening LDCT studies to be “batched” and read outside of the flow of clinically indicated studies by a subset of radiologists committed to lung cancer screening, significantly reducing the burden of screening on the overall practice. From a strictly business standpoint, many screening studies lead to additional clinically indicated studies, nodule follow-up for example, and it has been shown that these downstream studies can support many components of a lung cancer screening program.


JM: The emerging evidence is that community hospital systems are implementing lung cancer screening with results as least as good as the NLST results and people are going to be expecting to have access to such high quality services this service is rolling out.


CCT: Radiology was on board as it is a revenue generator for them with screening, PET scans, interventional procedures. The issue related to who is responsible to collect data required for reporting, required eligibility data, and surveillance was discussed and these areas of responsibility were assigned across the program.


CCHS: Pulmonary department encouraged our radiologists to become certified to read low dose studies


CF: This has been difficult because of their perceived loss of revenue. It remains a work in progress but has come a long way since we started. We now consistently get reports per Lung RADS protocol.

AM: Our program appealed to desire for organizational leadership as a result of involvement in this clinically impactful multidisciplinary program, and appeal to desire for professional advancement through content expertise in this emerging new field within pulmonary medicine.


MD: Most pulmonary specialists have experience with advanced lung cancer diagnosis and its complications, and would welcome the opportunity to participate in early detection. One of the most important skills pulmonary can bring to lung cancer screening is in the management of pulmonary nodules. However, very few nodules will require a procedure, such as bronchoscopy. Lung cancer screening is neither an opportunity to greatly expand procedures, or an activity that will overwhelm a practice with invasive procedures. Most nodules detected through screening can be determined as benign or likely malignant with serial imaging alone. Patients will appreciate the support and patience that can lead to successful treatment of an early stage lung cancer detected through screening, or the determination that a suspicious nodule is actually benign, and associate those outcomes with the pulmonary providers.


CL: Pulmonologists have significant experience in diagnosing, staging and managing lung cancer. There is also significant experience in the assessment of the pulmonary nodule. The risk stratification that occurs in lung screening, as well as the standardization of Lung-RADS reporting, is to the pulmonologists’ benefit. It also provides the pulmonologist opportunity to have important teachable opportunities in smoking cessation counseling, as well assessing and establishing the COPD diagnosis. It also provides opportunity to develop centers of excellence and enhance the role of an interventional pulmonary program and subspecialty research. The well-rounded focus on lung health for patients is valued by patients


CCT: Pulmonary is central to this program as they are the “first line” in diagnosing, staging, and deciding on the next step for the patient with a pulmonary nodule. Many patients prefer to see a pulmonologist even if their nodule could be managed with serial follow-up. This is to speak with a knowledgeable specialist regarding lung nodules, to review their imaging, and to understand the likelihood that the nodule(s) could be a worrisome process.


CF: Pulmonary developed and runs the program.


CCHS: Our program was initiated by the pulmonary department

How did you get primary care providers on-board when setting up your CT lung screening program?


JLM: Critical need moving forward since their professional societies are not supportive of screening.


CCT: Primary care is crucial to the success of a program. Including primary care leaders from the beginning in discussions related to starting a screening program is important. Educating the primary care provider base is a first step, which can be done through grand rounds, educational materials, primary care meetings, and inclusion on committees. In our program, a number of primary care providers felt this was all their role and they did not want their patients referred automatically to a program. Some would prefer to work up the nodule themselves and provide ongoing surveillance of nodules not requiring a work-up imminently. Others find this to be “added work” and they would prefer the program follow all patients enrolled in the screening program clinically. The variability makes it very challenging to have a structured and systematic program that ensures appropriate screening and follow-up. We have found less and less of this approach over time with education and experience with our program the multidisciplinary team, the nurse navigator, patient feedback, and in some instances provider experience with a new lung cancer following a period of loss to follow-up.


ABK: The co-founder of the RLRL program (ABM) went to primary care physician sites and provided a one hour CME briefing on lung cancer screening at the start of the program. The briefing described the evidence for screening the protocols established by the RLRL team addressed concerns including concern about increased workload by pointing out only a small number of screening participants would need follow-up. There is a primary care physician on the Steering Committee and committee members provide updates on progress and benefits including early lung cancers found and the opportunity improved health with smoking cessation with electronic communication, stories in hospital newsletter and Grand Rounds presentations


CF: We did a pilot program with a few of our PCPs with a large patient base and tried to incorporate PCPs that regularly refer patient’s for LDCT chest for lung cancer screening and those who rarely refer. This was helpful in identifying barriers to scanning. This remains an ongoing challenge. The program tries to provide regular education to PCPs regarding need for discussion of LDCT screening in eligible patients and scheduling of exam if indicated.

JLM: Critical need moving forward since their professional societies are not supportive of screening.


CCT: Primary care is crucial to the success of a program. Including primary care leaders from the beginning in discussions related to starting a screening program is important. Educating the primary care provider base is a first step, which can be done through grand rounds, educational materials, primary care meetings, and inclusion on committees. In our program, a number of primary care providers felt this was all their role and they did not want their patients referred automatically to a program. Some would prefer to work up the nodule themselves and provide ongoing surveillance of nodules not requiring a work-up imminently. Others find this to be “added work” and they would prefer the program follow all patients enrolled in the screening program clinically. The variability makes it very challenging to have a structured and systematic program that ensures appropriate screening and follow-up. We have found less and less of this approach over time with education and experience with our program the multidisciplinary team, the nurse navigator, patient feedback, and in some instances provider experience with a new lung cancer following a period of loss to follow-up.


ABK: The co-founder of the RLRL program (ABM) went to primary care physician sites and provided a one hour CME briefing on lung cancer screening at the start of the program. The briefing described the evidence for screening the protocols established by the RLRL team addressed concerns including concern about increased workload by pointing out only a small number of screening participants would need follow-up. There is a primary care physician on the Steering Committee and committee members provide updates on progress and benefits including early lung cancers found and the opportunity improved health with smoking cessation with electronic communication, stories in hospital newsletter and Grand Rounds presentations


CF: We did a pilot program with a few of our PCPs with a large patient base and tried to incorporate PCPs that regularly refer patient’s for LDCT chest for lung cancer screening and those who rarely refer. This was helpful in identifying barriers to scanning. This remains an ongoing challenge. The program tries to provide regular education to PCPs regarding need for discussion of LDCT screening in eligible patients and scheduling of exam if indicated

LM: Lung cancer is the leading cause of death across the world. With the results of the NLST, the USPSTF now endorses lung cancer screening as a service that is associated with the potential to save current and former smokers from dying of lung cancer. It is a challenging process but many centers are now demonstrating that they can provide this cost-effective service together with smoking cessation services which are even more cost effective and help a broad fraction of adults that would use their hospitals/clinics services. With the transition to value-based care, providing such services may be key to cultivating a healthier patient population. While this service emerged first in the United States, lung cancer screening is attracting considerable attention internationally as a transformative new approach to mitigating lung cancer deaths.

BM/SR: There are approximately 60,000,000 women qualified for mammography and 10,000,000 patients qualified for CT lung screening. Therefore a rough estimate could be for every six mammograms your hospital performs, you should perform one CT lung screening exam. For example, if your institution performs 30,000 screening mammograms per year you should be performing roughly 100 CT lung screening exams per week (30,000/6 = 5000/50 wk = 100). An alternative method is to use the fact that at steady state in mammography there are nine women enrolled with prior exams for every one new woman entering the program. As such if you could estimate your baseline CT lung screening volume the steady state volume of the program should be 10x times that number. For example, if you plan to enroll 20 new patients per week at steady state you program should have a volume of 200 screening exams per week.


RSW: This is going to be highly variable depending on the volume of the patient population served, patient population characteristics (risk factors/eligibility), uptake of screening among providers and patients (dependent on leadership support, aggressiveness of marketing, patient and provider interest, etc.), capacity of program, etc. Even between programs that are otherwise similar (e.g. eight site VA demonstration project of LCS), volume of screened patients varied dramatically. So I’m not sure how useful it will be for programs to figure out their own expected volume to see a huge range from other programs.


GM/DTC/CCT: Estimates can be based on the size of the population, percentage of smokers within your population, nodule detection rate in your area and percentage of your institution’s market share.

CF/BM/SR/DTC/RSW/KS/CCT: CMS established reimbursement criteria for LCS exams. Included in those requirements is that specific data must be submitted to an approved clinical practice registry.9

Currently there is only one approved CMS registry which has additional data elements required/requested and requires use of Lung-RADS™.16,17

Required Elements

Exam details:
Facility ID number, patient name, exam date

General:
Smoking status in pack years
Smoking cessation counseling
Documentation of shared decision making
Height, weight, comorbidities, cancer history
Radiologist name, ordering provider and NPI
Indication for the exam
Exam modality, manufacturer, radiation exposure
CT exam results by Lung-RADS™ category
Other abnormalities- CT exam result S modifier
Prior history of lung cancer and years since diagnosis

Follow-up within 1 year
Documentation of an exam anytime within prior 12 months and date
Follow-up diagnostic for tissue:

  • Tissue Diagnosis
  • Tissue diagnosis method
  • Location from which sample was obtained
  • Histology
  • Stage- Clinical or pathologic
  • Overall stage
  • T, N, M status
  • Period of follow-up for incidence (in months)

Additional Risk Factors:
Education level, radiation exposure, occupational exposures, history of cancers associated with a higher risk of lung cancer, lung cancer in first-degree relative, other family history of lung cancer, COPD, pulmonary fibrosis, secondhand smoke exposure.
Name of person performing data collection for the exam, submission date.

AM: The steering committee evaluates the number of referrals by primary care provider, qualified rate, best practice advisory (BPA) activity, how patients access program, patient satisfaction surveys, time between referral and exam date, no-show rate, program discharge rate, demographic and racial inequities, smoking cessation rates, and program outreach efforts. This data is collected through dedicated LCS database, which is derived from radiology information system and electronic health record and is reported annually to the steering committee. Program navigators are responsible for collating and ensuring data entry is performed accurately. Data is reported to the steering committee, reading radiologists, and to a CMS approved registry. Navigators oversee electronic submission of data to a CMS approved registry. Cancer detection rate, qualified rate, patient enrollment, discharges, and program outreach activities are sent out weekly to steering committee and reviewed in person at steering committee meetings every other month.


CCT/KK: There are two major areas of data that are tracked by our program. Those metrics necessary for reporting to the CMS registry is one major area. The other group of metrics is those related to quality of our program and providing excellent patient care. The program tracks the number of patients referred to the program, the number of screening CTs, eligibility criteria, access times for each diagnostic and therapeutic step, number and percentage of each therapeutic area, and number of patients cared for outside of our system. We also have a prospective and retrospective surveillance program, which tracks follow-up and provides outreach to patients and providers for overdue follow-up. Data is collected by radiology, oncology, thoracic surgery, our screening program, and nodule program. We review program related metrics internally through our steering committee and through the oncology steering committee. Externally, data is reported to the ACR registry, as well as specific registries associated with oncology and radiation oncology, and thoracic surgery.


AR: Because of previous experience with ELCAP,15 we collect for Mount Sinai registry/ Delaware registry and all ACR data points for Medicare and additional public health data fields for the state program.