Implementation of Comprehensive Lung Cancer Screening Programs — Thinking Beyond the CT
In 2011, the National Cancer Institute (NCI) reported the results of the largest lung cancer screening trial to date — the National Lung Screening Trial (NLST). More than 50,000 patients participated in the trial, which compared lung cancer detection via annual low-dose computed tomography (LDCT) versus chest radiography over a three-year interval. Results from this trial confirmed what most radiologists already suspected — those in the LDCT group had improved cancer detection rates and had a significant reduction in lung cancer mortality.
Based upon the data from this trial and others, statements from large national agencies were issued in support of the use of annual LDCT for lung cancer screening, including a Grade B recommendation from the U.S. Preventative Services Task Force in 2013 and eligibility for reimbursement by CMS in 2015. Fast forward to 2018 and LDCT is now widely available for lung cancer screening.
Like many radiology departments, we initially approached lung cancer screening from a purely technical perspective — developing protocols for low-dose chest CTs and adapting the use of ACR’s Lung-RADS™ for the standardized interpretation of such exams. We soon realized that the ability to perform and interpret an LDCT is only one component of effective lung cancer screening — a process that begins and ends outside of radiology.
In response to the challenges of instituting lung cancer screening, formal lung cancer screening programs (LCSPs) have been developed. From patient selection, to performance and interpretation of LDCTs, to management of screening results, these multidisciplinary teams ensure lung cancer screening is patient-centered but also meets technical reimbursement standards. Our need for such an LCSP was initially recognized by one of my co-residents (Justin Stowell, MD, currently a fellow in thoracic and cardiac imaging at Massachusetts General Hospital) who spearheaded a resident-driven effort to establish such a program at our institution.
Establishing our LCSP began by examining the CMS reimbursement model and using it to divide the screening process into the three stages: pre-screening, screening, and post-screening. We initially focused on the screening stage — the performance and interpretation of LDCTs — as it was the most radiology-centered.
An internal audit of LDCTs performed over an initial 30-day period revealed that based upon radiology-specific factors alone, none of the exams we interpreted would be eligible for reimbursement-based upon CMS criteria. While most exams were interpreted accurately and given appropriate follow-up recommendations, they lacked a simple statement assigning a specific Lung-RADS™ designation. In response to these findings we held a resident conference on LDCT interpretation and reporting and also updated the macro for LDCT exams to include a field for Lung-RADS™ designation. With this simple intervention, our next 30-day audit revealed that more than 80 percent of our exams now met the radiology-specific criteria for reimbursement, previously zero. While this reporting problem was easy to fix, it was one we would otherwise not have been aware of had we not examined CMS requirements and performed an internal audit.
Issues with the remaining stages of screening were mostly centered around adherence to patient eligibility (pre-screening) and management/reporting of screening outcomes (post-screening). Having a multidisciplinary LCSP team in place allowed us to build partnerships to address these issues as they were largely out of the direct control of radiology. Some of the interventions we worked on included changing the ordering process through the EMR to include hard-stops for ineligible patients (ex: patients too young for screening), holding grand rounds on lung cancer screening for our referring colleagues (internal medicine and family medicine), partnering with a pulmonary nurse navigator and the existing thoracic tumor board to streamline management of positive results, and adapting existing infrastructure to report our results to the ACR Lung Cancer Screening Registry as mandated by CMS (ex: support staff already reporting to the National Mammography Database).
The foremost benefit of this resident-driven LCSP has been ensuring quality screening for our patients. We can now feel confident that the right patients are selected for screening, that the exams are performed with appropriate technique and interpreted accurately, and that patients are supported throughout the process — particularly in the event of a positive result. The creation of this program has also meant that our hospital (and radiology department) are appropriately reimbursed for the exams we perform. As a large component of our patient population is Medicare/Medicaid dependent, this reimbursement ensures that we may continue to offer this and other services to our patients.
Offering lung cancer screening requires more than just the ability to perform and interpret a low-dose chest CT — it requires a multidisciplinary support system for patients and clinicians, as well as the infrastructure to address the technical and economic considerations of screening. Leading such multidisciplinary efforts through LCSPs affords radiologists the opportunity to demonstrate a commitment to patient- and family- centered care and contribute to the evolving perception of our specialty as a value-based clinical consultant. Moreover, our experience shows that trainees can successfully lead such initiatives and look for similar opportunities within their own institution to exact change.
By Jennifer Buckley, MD, Chief Resident at University of Missouri-Kansas City.