Benchmarking

An Example of the Rate of S Positives from Lahey Medical Center

Site
Percentage of S Positive Findings
Kidney
19.8%
Thyroid
17.6%
Liver
16.3%
Esophagus
5.7%
Adrenal
4.9%
Pancreas
4.4%
Breast
4.4%
Spine
4.0%
Spleen
3.5%
Aorta
3.5%

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Appendix II: An Example of the Rate of S Positives from Lahey Medical Center

Coronary Artery Calcifications and Emphysema

Data from 1/2012 – 8/2014 (n = 1336)

No coronary artery calcifications
23.9%
Mild coronary artery calcifications
28.9%
Moderate coronary artery calcifications
25.4%
Marked coronary artery calcifications
21.9%
No emphysema
43.3%
Mild emphysema
38.6%
Moderate emphysema
14.3%
Marked emphysema
3.8%
Some level of coronary artery calcifications or emphysema (or both)
88.3%
Either marked coronary artery calcifications or marked emphysema (or both)
24.7%

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Coronary Artery Calcifications And Emphysema

Care Escalation

Care Escalation for Suspicious (LR4) Findings – 1/2012 through 3/2017
Intervention
LR4 Patients
Dx Lung Ca
Pre-Test Probability of FP Intervention
Non-Invasive
Pulmonary Consult
93.2%
35.0%
5.5%
PET/CT
50.0%
54.1%
2.1%
Invasive
Percutaneous Biopsy
13.5%
65.2%
0.4%
Bronchoscopy w/Biopsy
14.1%
75.0%
0.3%
Bronchoscopy w/o Biopsy
1.5%
80.0%
0.0%
Surgery
26.8%
78.0%
0.5%
Any Invasive Intervention
43.8%
71.1%
1.2%

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APPENDIX III: CARE ESCALATION

Diagnosis by Screening Round from Lahey Medical Center, Burlington MA

24 Months of Exams with 3+ Months of Follow Up (2015-2016)

Screen Round
Negative
(LR 0, 1, 2)
Positive
(LR 3, 4A, 4B, 4X)
Suspicious
(LR 4A, 4B, 4X)
Dx Lung Ca
(LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
False
Negative
Total
S Positive
T0
842
85.5%
143
14.5%
63
6.4%
20
2.0%
14.0%
0.0%
31.7%
68.4%
2
0.2%
985
83
8.4%
T1
686
91.8%
61
8.2%
27
3.6%
10
1.3%
16.4%
0.0%
37.0%
50.0%
1
0.1%
747
21
2.8%
T2
613
95.5%
29
4.5%
14
2.2%
3
0.5%
10.3%
0.0%
21.4%
16.7%
0
0.0%
642
14
2.2%
T3+
545
94.5%
32
5.5%
17
2.9%
6
1.0%
18.8%
0.0%
35.3%
50.0%
0
0.0%
577
10
1.7%
Total
2676
91.0%
265
9.0%
121
4.1%
39
1.3%
14.7%
0.0%
32.2%
53.7%
3
0.1%
2941
128
4.4%

Breakdown by reading radiologist. NOTE: Only radiologists reading 100+ screening exams are included in analysis.

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24 Months of Exams with 3+ Months of Follow Up (2015-2016)

2015-2016 Baseline (T0)

Radiologist
LR0 LR1 LR2 LR3 LR4A LR4B LR4X
Total
A
0
0.0%
6
18.8%
24
75.0%
2
6.3%
0
0.0%
0
0.0%
0
0.0%
32
B
0
0.0%
20
6.2%
260
80.0%
24
7.4%
12
3.7%
7
2.2%
2
0.6%
325
C
0
0.0%
8
19.5%
24
58.5%
4
9.8%
2
4.9%
2
4.9%
1
2.4%
41
D
0
0.0%
111
27.2%
227
55.6%
42
10.3%
16
3.9%
6
1.5%
6
1.5%
408
E
0
0.0%
16
10.5%
121
79.1%
7
4.6%
5
3.3%
4
2.6%
0
0.0%
153
Total
0
0.0%
161
16.8%
656
68.4%
79
8.2%
35
3.6%
19
2.0%
9
0.9%
959

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2015-2016 Baseline (T0)

2015-2016 Baseline (T0), Table 2

Radiologist
Negative
(LR 0, 1, 2)
(LR 3, 4A, 4B, 4X) (LR 4A, 4B, 4X) (LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
Negative
Total
A
30
93.8%
2
6.3%
0
0.0%
0
0.0%
0.0%
0.0%
0
0.0%
32
3
9.4%
B
280
86.2%
45
13.8%
21
6.5%
7
2.2%
15.6%
0.0%
33.3%
71.4%
1
0.3%
325
29
8.9%
C
32
78.0%
9
22.0%
5
12.2%
2
4.9%
22.2%
0.0%
40.0%
100.0%
0
0.0%
41
2
4.9%
D
338
82.8%
70
17.2%
28
6.9%
8
2.0%
11.4%
0.0%
28.6%
66.7%
1
0.2%
408
36
8.8%
E
137
89.5%
16
10.5%
9
5.9%
3
2.0%
18.8%
0.0%
33.3%
50.0%
0
0.0%
153
11
7.2%
Total
817
85.2%
142
14.8%
63
6.6%
20
2.1%
14.1%
0.0%
31.7%
68.4%
2
0.2%
959
81
8.4%

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2015-2016 Baseline (T0)

2015-2016 Annual (T1+)

Radiologist
LR0 LR1 LR2 LR3 LR4A LR4B LR4X
Total
A
0
0.0%
24
18.6%
100
77.5%
3
2.3%
1
0.8%
1
0.8%
0
0.0%
129
B
0
0.0%
46
8.1%
483
84.6%
17
3.0%
10
1.8%
8
1.4%
7
1.2%
571
C
0
0.0%
13
14.3%
73
80.2%
1
1.1%
3
3.3%
0
0.0%
1
1.1%
91
D
0
0.0%
213
25.7%
553
66.7%
37
4.5%
10
1.2%
13
1.6%
3
0.4%
829
E
0
0.0%
42
14.2%
247
83.7%
5
1.7%
0
0.0%
0
0.0%
1
0.3%
295
Total
0
0.0%
338
17.7%
1456
76.0%
63
3.3%
24
1.3%
22
1.1%
12
0.6%
1915

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2015-2016 Annual (T1+)

2015-2016 Annual (T1+), Table 2

Radiologist
Negative
(LR 0, 1, 2)
Positive
(LR 3, 4A, 4B, 4X)
Suspicious
(LR 4A, 4B, 4X)
Dx Lung Ca
(LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
False
Negative
Total
S Positive
A
124
96.1%
5
3.9%
2
1.6%
2
1.6%
40.0%
0.0%
100.0%
100.0%
0
0.0%
129
1
0.8%
B
529
92.6%
42
7.4%
25
4.4%
8
1.4%
19.0%
0.0%
32.0%
37.5%
0
0.0%
571
9
1.6%
C
86
94.5%
5
5.5%
4
4.4%
0
0.0%
0.0%
0.0%
0.0%
0
0.0%
91
2
2.2%
D
766
92.4%
63
7.6%
26
3.1%
8
1.0%
12.7%
0.0%
30.8%
38.5%
1
0.1%
829
28
3.4%
E
289
98.0%
6
2.0%
1
0.3%
1
0.3%
16.7%
0.0%
100.0%
0
0.0%
295
5
1.7%
Total
1794
93.7%
121
6.3%
58
3.0%
19
1.0%
15.7%
0.0%
32.8%
40.9%
1
0.1%
1915
45
2.3%

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2015-2016 Annual (T1+)

BJM/SR: In our program LR0 exams are exceedingly rare and typically result from incomplete scan range or significant respiratory motion. In the past 5,000 exams we have had one LR0 result (0.02%). When this occurs, we finalize the report as a LR0 and recall the patient to have the exam repeated at no extra charge and issue a second finalized report after the patient returns.

Diagnosis by Screening Round from Lahey Medical Center, Burlington MA

24 Months of Exams with 3+ Months of Follow Up (2015-2016)

Screen Round
Negative
(LR 0, 1, 2)
Positive
(LR 3, 4A, 4B, 4X)
Suspicious
(LR 4A, 4B, 4X)
Dx Lung Ca
(LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
False
Negative
Total
S Positive
T0
842
85.5%
143
14.5%
63
6.4%
20
2.0%
14.0%
0.0%
31.7%
68.4%
2
0.2%
985
83
8.4%
T1
686
91.8%
61
8.2%
27
3.6%
10
1.3%
16.4%
0.0%
37.0%
50.0%
1
0.1%
747
21
2.8%
T2
613
95.5%
29
4.5%
14
2.2%
3
0.5%
10.3%
0.0%
21.4%
16.7%
0
0.0%
642
14
2.2%
T3+
545
94.5%
32
5.5%
17
2.9%
6
1.0%
18.8%
0.0%
35.3%
50.0%
0
0.0%
577
10
1.7%
Total
2676
91.0%
265
9.0%
121
4.1%
39
1.3%
14.7%
0.0%
32.2%
53.7%
3
0.1%
2941
128
4.4%

Breakdown by reading radiologist. NOTE: Only radiologists reading 100+ screening exams are included in analysis.

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24 Months of Exams with 3+ Months of Follow Up (2015-2016)

2015-2016 Baseline (T0)

Radiologist
LR0 LR1 LR2 LR3 LR4A LR4B LR4X
Total
A
0
0.0%
6
18.8%
24
75.0%
2
6.3%
0
0.0%
0
0.0%
0
0.0%
32
B
0
0.0%
20
6.2%
260
80.0%
24
7.4%
12
3.7%
7
2.2%
2
0.6%
325
C
0
0.0%
8
19.5%
24
58.5%
4
9.8%
2
4.9%
2
4.9%
1
2.4%
41
D
0
0.0%
111
27.2%
227
55.6%
42
10.3%
16
3.9%
6
1.5%
6
1.5%
408
E
0
0.0%
16
10.5%
121
79.1%
7
4.6%
5
3.3%
4
2.6%
0
0.0%
153
Total
0
0.0%
161
16.8%
656
68.4%
79
8.2%
35
3.6%
19
2.0%
9
0.9%
959

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2015-2016 Baseline (T0)

2015-2016 Baseline (T0), Table 2

Radiologist
Negative
(LR 0, 1, 2)
(LR 3, 4A, 4B, 4X) (LR 4A, 4B, 4X) (LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
Negative
Total
A
30
93.8%
2
6.3%
0
0.0%
0
0.0%
0.0%
0.0%
0
0.0%
32
3
9.4%
B
280
86.2%
45
13.8%
21
6.5%
7
2.2%
15.6%
0.0%
33.3%
71.4%
1
0.3%
325
29
8.9%
C
32
78.0%
9
22.0%
5
12.2%
2
4.9%
22.2%
0.0%
40.0%
100.0%
0
0.0%
41
2
4.9%
D
338
82.8%
70
17.2%
28
6.9%
8
2.0%
11.4%
0.0%
28.6%
66.7%
1
0.2%
408
36
8.8%
E
137
89.5%
16
10.5%
9
5.9%
3
2.0%
18.8%
0.0%
33.3%
50.0%
0
0.0%
153
11
7.2%
Total
817
85.2%
142
14.8%
63
6.6%
20
2.1%
14.1%
0.0%
31.7%
68.4%
2
0.2%
959
81
8.4%

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2015-2016 Baseline (T0)

2015-2016 Annual (T1+)

Radiologist
LR0 LR1 LR2 LR3 LR4A LR4B LR4X
Total
A
0
0.0%
24
18.6%
100
77.5%
3
2.3%
1
0.8%
1
0.8%
0
0.0%
129
B
0
0.0%
46
8.1%
483
84.6%
17
3.0%
10
1.8%
8
1.4%
7
1.2%
571
C
0
0.0%
13
14.3%
73
80.2%
1
1.1%
3
3.3%
0
0.0%
1
1.1%
91
D
0
0.0%
213
25.7%
553
66.7%
37
4.5%
10
1.2%
13
1.6%
3
0.4%
829
E
0
0.0%
42
14.2%
247
83.7%
5
1.7%
0
0.0%
0
0.0%
1
0.3%
295
Total
0
0.0%
338
17.7%
1456
76.0%
63
3.3%
24
1.3%
22
1.1%
12
0.6%
1915

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2015-2016 Annual (T1+)

2015-2016 Annual (T1+), Table 2

Radiologist
Negative
(LR 0, 1, 2)
Positive
(LR 3, 4A, 4B, 4X)
Suspicious
(LR 4A, 4B, 4X)
Dx Lung Ca
(LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
False
Negative
Total
S Positive
A
124
96.1%
5
3.9%
2
1.6%
2
1.6%
40.0%
0.0%
100.0%
100.0%
0
0.0%
129
1
0.8%
B
529
92.6%
42
7.4%
25
4.4%
8
1.4%
19.0%
0.0%
32.0%
37.5%
0
0.0%
571
9
1.6%
C
86
94.5%
5
5.5%
4
4.4%
0
0.0%
0.0%
0.0%
0.0%
0
0.0%
91
2
2.2%
D
766
92.4%
63
7.6%
26
3.1%
8
1.0%
12.7%
0.0%
30.8%
38.5%
1
0.1%
829
28
3.4%
E
289
98.0%
6
2.0%
1
0.3%
1
0.3%
16.7%
0.0%
100.0%
0
0.0%
295
5
1.7%
Total
1794
93.7%
121
6.3%
58
3.0%
19
1.0%
15.7%
0.0%
32.8%
40.9%
1
0.1%
1915
45
2.3%

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2015-2016 Annual (T1+)

BJM, SR: This is a critical metric, which should be tracked and disclosed to patients as part of the SDM process. Excerpt from JTI article, “The spectrum of complications associated with breast and lung screening interventions differ significantly. For breast biopsy, complications such as bleeding and infection are infrequent, usually easily managed, and rarely require hospitalization.24

Lung biopsy complications include those observed in breast biopsy as well as pulmonary bleeding, infection, and pneumothorax. These latter may occasionally require hospitalization and in very rare instances can be life-threatening. Six deaths were observed in the NLST population occurring within 60 days of interventions performed on patients with positive screening examinations who did not have cancer (false positives). Given the severity of these associated complications, lung cancer screening interventions should be carefully directed toward patients with a likelihood for malignancy that is high enough to justify the elevated risks. LungRADS coding helps practices identify the 95% to 96% of patients who do not require evaluation for biopsy (LungRADS 3 or less) from the 4% to 5% of patients in whom biopsy may be a consideration (LungRADS 4). In addition, LungRADS requires a slightly higher pretest probability of malignancy (5% vs. 2% in mammography) before considering intervention. For the 2% to 5% risk group, a short interval follow-up low dose chest CT in 6 months is recommended to identify the subset of patients for whom intervention may be appropriate. As a result, the positive predictive value (PPV) of a CT lung screening biopsy should exceed the mammography benchmark of 33%.”

xCare Escalation

Care Escalation for Suspicious (LR4) Findings – 1/2012 through 3/2017

Intervention
LR4 Patients
Dx Lung Ca
Pre-Test Probability of FP Intervention
Non-Invasive
Pulmonary Consult
93.2%
35.0%
5.5%
PET/CT
50.0%
54.1%
2.1%
Invasive
Percutaneous Biopsy
13.5%
65.2%
0.4%
Bronchoscopy w/ Biopsy
14.1%
75.0%
0.3%
Bronchoscopy w/o Biopsy
1.5%
80.0%
0.0%
Surgery
26.8%
78.0%
0.5%
Any Invasive Intervention 43.8% 71.1% 1.2%

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Care Escalation for Suspicious (LR4) Findings – 1/2012 through 3/2017

BJM/SR: This is best assessed from time of positive or suspicious finding to cancer diagnosis.

BJM/SR: Overall average time in our program at Lahey from LR4 reading to diagnosis is 75 days; overall average time among those with LR4B readings is 27 days.

EH: LR3 and LR4 combined are running around 12-15% combined. I think it is important to note that the prevalence of nodules and their sizes is going to vary by geography. There is no “right” or single or simple answer here. It might make sense to aggregate geographic areas once this data is better known.

Diagnosis by Screening Round from Lahey Medical Center, Burlington MA

24 Months of Exams with 3+ Months of Follow Up (2015-2016)

Screen Round
Negative
(LR 0, 1, 2)
Positive
(LR 3, 4A, 4B, 4X)
Suspicious
(LR 4A, 4B, 4X)
Dx Lung Ca
(LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
False
Negative
Total
S Positive
T0
842
85.5%
143
14.5%
63
6.4%
20
2.0%
14.0%
0.0%
31.7%
68.4%
2
0.2%
985
83
8.4%
T1
686
91.8%
61
8.2%
27
3.6%
10
1.3%
16.4%
0.0%
37.0%
50.0%
1
0.1%
747
21
2.8%
T2
613
95.5%
29
4.5%
14
2.2%
3
0.5%
10.3%
0.0%
21.4%
16.7%
0
0.0%
642
14
2.2%
T3+
545
94.5%
32
5.5%
17
2.9%
6
1.0%
18.8%
0.0%
35.3%
50.0%
0
0.0%
577
10
1.7%
Total
2676
91.0%
265
9.0%
121
4.1%
39
1.3%
14.7%
0.0%
32.2%
53.7%
3
0.1%
2941
128
4.4%

Breakdown by reading radiologist. NOTE: Only radiologists reading 100+ screening exams are included in analysis.

Click to View Table:

24 Months of Exams with 3+ Months of Follow Up (2015-2016)

2015-2016 Baseline (T0)

Radiologist
LR0 LR1 LR2 LR3 LR4A LR4B LR4X
Total
A
0
0.0%
6
18.8%
24
75.0%
2
6.3%
0
0.0%
0
0.0%
0
0.0%
32
B
0
0.0%
20
6.2%
260
80.0%
24
7.4%
12
3.7%
7
2.2%
2
0.6%
325
C
0
0.0%
8
19.5%
24
58.5%
4
9.8%
2
4.9%
2
4.9%
1
2.4%
41
D
0
0.0%
111
27.2%
227
55.6%
42
10.3%
16
3.9%
6
1.5%
6
1.5%
408
E
0
0.0%
16
10.5%
121
79.1%
7
4.6%
5
3.3%
4
2.6%
0
0.0%
153
Total
0
0.0%
161
16.8%
656
68.4%
79
8.2%
35
3.6%
19
2.0%
9
0.9%
959

Click to View Table:

2015-2016 Baseline (T0)

2015-2016 Baseline (T0), Table 2

Radiologist
Negative
(LR 0, 1, 2)
(LR 3, 4A, 4B, 4X) (LR 4A, 4B, 4X) (LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
Negative
Total
A
30
93.8%
2
6.3%
0
0.0%
0
0.0%
0.0%
0.0%
0
0.0%
32
3
9.4%
B
280
86.2%
45
13.8%
21
6.5%
7
2.2%
15.6%
0.0%
33.3%
71.4%
1
0.3%
325
29
8.9%
C
32
78.0%
9
22.0%
5
12.2%
2
4.9%
22.2%
0.0%
40.0%
100.0%
0
0.0%
41
2
4.9%
D
338
82.8%
70
17.2%
28
6.9%
8
2.0%
11.4%
0.0%
28.6%
66.7%
1
0.2%
408
36
8.8%
E
137
89.5%
16
10.5%
9
5.9%
3
2.0%
18.8%
0.0%
33.3%
50.0%
0
0.0%
153
11
7.2%
Total
817
85.2%
142
14.8%
63
6.6%
20
2.1%
14.1%
0.0%
31.7%
68.4%
2
0.2%
959
81
8.4%

Click to View Table:

2015-2016 Baseline (T0)

2015-2016 Annual (T1+)

Radiologist
LR0 LR1 LR2 LR3 LR4A LR4B LR4X
Total
A
0
0.0%
24
18.6%
100
77.5%
3
2.3%
1
0.8%
1
0.8%
0
0.0%
129
B
0
0.0%
46
8.1%
483
84.6%
17
3.0%
10
1.8%
8
1.4%
7
1.2%
571
C
0
0.0%
13
14.3%
73
80.2%
1
1.1%
3
3.3%
0
0.0%
1
1.1%
91
D
0
0.0%
213
25.7%
553
66.7%
37
4.5%
10
1.2%
13
1.6%
3
0.4%
829
E
0
0.0%
42
14.2%
247
83.7%
5
1.7%
0
0.0%
0
0.0%
1
0.3%
295
Total
0
0.0%
338
17.7%
1456
76.0%
63
3.3%
24
1.3%
22
1.1%
12
0.6%
1915

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2015-2016 Annual (T1+)

2015-2016 Annual (T1+), Table 2

Radiologist
Negative
(LR 0, 1, 2)
Positive
(LR 3, 4A, 4B, 4X)
Suspicious
(LR 4A, 4B, 4X)
Dx Lung Ca
(LR 5)
PPV
LR3 PPV
LR4 PPV
LR4B PPV
False
Negative
Total
S Positive
A
124
96.1%
5
3.9%
2
1.6%
2
1.6%
40.0%
0.0%
100.0%
100.0%
0
0.0%
129
1
0.8%
B
529
92.6%
42
7.4%
25
4.4%
8
1.4%
19.0%
0.0%
32.0%
37.5%
0
0.0%
571
9
1.6%
C
86
94.5%
5
5.5%
4
4.4%
0
0.0%
0.0%
0.0%
0.0%
0
0.0%
91
2
2.2%
D
766
92.4%
63
7.6%
26
3.1%
8
1.0%
12.7%
0.0%
30.8%
38.5%
1
0.1%
829
28
3.4%
E
289
98.0%
6
2.0%
1
0.3%
1
0.3%
16.7%
0.0%
100.0%
0
0.0%
295
5
1.7%
Total
1794
93.7%
121
6.3%
58
3.0%
19
1.0%
15.7%
0.0%
32.8%
40.9%
1
0.1%
1915
45
2.3%

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2015-2016 Annual (T1+)

Protocols and Benchmarking Examples

CT Protocols

   Philips iCT  GE Lightspeed VCT  GE Discovery VCT  Siemens DS Definition
MA 60 50 70 eff MAS 30-50MA
KV 100 100 100 100
Pitch 0.993 1.375: 1/55mm/rotation 1.375: 1/55mm/rotation 0.9
Collimation 128 x 0.625 mm 64 x 0.625mm 64 x 0.625mm 24 x 1.2mm
Reconstruction 1.25 x 0.625 mm soft/lung 16 x 2.5 mm Axial MIP Coronal, Sagittal 1.25 x 0.625 mm soft/lung 16 x 2.5 mm Axial MIP Coronal, Sagittal 1.25 x 0.625 mm soft/lung 16 x 2.5 mm Axial MIP Coronal, Sagittal 1.5 x 0.75 mm soft/lung 16 x 2.5 mm Axial MIP Coronal, Sagittal
Rotation Time 0.5s 0.6s 0.6s 0.5s
CTDi ~1.22 ~1.48 ~1.56 ~1.19
Software iDOSE (iterative recon) ACIR (iterative recon) standard processing IRIS (iterative recon)
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APPENDIX IV: CT PROTOCOLS

The following may be measures a program could use to assess detection rates, false positive rates, and diagnostic and therapeutic rates. These are not required elements for reporting or insurance reimbursement for a LCS program; however, programs may find these useful for internal tracking and quality control.

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