Centralizing Lung Cancer Screening Programs: A Quality Improvement Project

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Abstract Introduction: Societies and taskforces recommend annual low-dose CT scan (LDCT) for lung cancer screening (LCS) for individuals aged 50 to 80 years with at least 20 pack-year smoking history and current smokers or who quit within the past 15 years. LCS programs have adopted either a centralized consult-based model with a dedicated program coordinator, a hybrid model, or a decentralized program allowing all providers to order LDCT for LCS. However, screening is more than an imaging modality and requires shared decision making and proper timely follow-up (adherence). When LCS was open to all providers, LCS CT scans were at times inappropriately ordered for patients who do not qualify based on age or smoking history. In addition, adherence was low, which can contribute to harm and increased costs. Methods: To improve appropriateness and adherence to LCS, a taskforce led by the LCS coordinator, the radiology department and the pulmonary division decided to move towards centralization in early 2024, encouraging all providers to consult the LCS program. This helped limit orders of LDCT for LCS mostly to the LCS coordinator and pulmonary service. Despite more centralization, LCS remained a hybrid model where several primary care providers were still ordering LCS for their patients. LCS appropriateness and adherence were tracked at our facility through the National Center for Lung Cancer Screening Platform. A quality improvement project was submitted and approved by the research office at the WNY Veterans Administration Medical Center. Results: Data were reported from five consecutive quarters (2023 quarter 4 to 2024 quarter 4). The number of LCS consults received by the LCS coordinator increased by 45%. Patients enrolled in the LCS program had a group mean adherence of 98.1%, compared to 46.4% for those not enrolled, p-value: 2.792e-06 (<0.05). Weekly inappropriate ordering of LDCT LCS dropped from an average of 27.5 to 7.5 per week (Figure 1). The out-of-pocket cost of a LDCT LCS was estimated to be $131, helping save at least $2620 per week. Conclusion: Centralization of a LCS program improved appropriateness and adherence. This helps reduce harm and costs resulting from inappropriate testing. It also ensures timely follow-up on results, improving the quality of care provided. It is not certain that complete centralization is needed as opposed to a hybrid model. Future research is needed to confirm the benefits of a centralized LCS program, helping societies and taskforces incorporate such recommendations in national and international guidelines.

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