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June 2016 VOL 7, NO 5
The Impact of Patient Navigation in Low-Dose Computed Tomography Lung Screening
Kristi M. Griffith, MSN, RN, CHPN; Nora J. Barrett, BSN, RN, OCN; Kristi L. Case, MS, CHW; Susan W. Dahlin, BSN, RN, OCN; Stacey L. Webb, MPA-HCA, BSN, RN
Background: The results from the National Lung Cancer Screening Trial in 2012 showed a 20% relative decrease in mortality with the use of annual low-dose computed tomography (LDCT) lung scans for at-risk patients. Thus, an LDCT lung screening program was initiated in 2013; however, multiple barriers that might delay patient access to screening were encountered. One major obstacle to LDCT screening was scheduling the scan, with process delays of up to 21 days after the order was received by the navigator. Scheduling required multiple steps and resulted in delayed service and increased noncompliance because the sense of urgency decreased as time lapsed.
Objective: To decrease the time between the receipt of physician’s order for LDCT and date of actual screening.
Methods: A multidisciplinary team collaborated in an effort to improve LDCT efficiency. The scheduling process was one area targeted. In the improved process, the patient navigator, patient, and radiology scheduler directly connected via 3-way conferencing for more prompt direct scheduling, avoiding multiple phone calls and decreasing delay of scheduling.
Results: A total of 109 patients were included in our analysis. We found that the time between receipt of the LDCT order and actual scan was reduced by 3 days preintervention versus postintervention (13.5 ± 16.2 vs 10.1 ± 13.3 days, respectively).
Conclusion: With the streamlining in scheduling, there was a decrease in delay from order to actual screen. Evaluation of current program and improvement efforts continue to increase patient access to screenings and compliance with screenings, leading to better outcomes for patients.
According to the American Cancer Society, there were an estimated 221,200 new cases of lung cancer in the United States in 2015 and an estimated 158,040 deaths.1 Although the incidence is declining, lung cancer accounts for about 13% of all the new cases of cancer and about 27% of all cancer deaths. This makes lung cancer the leading cause of cancer-related deaths in the United States in both men and women. As with all cancers, detection of lung cancer at an early stage is critical to yield the best chance of outcome. Because lung cancer patients are generally asymptomatic in the early stages of disease, the majority of patients are diagnosed at advanced stages, when the 1- and 5-year survival rates are 26% and 4%, respectively.1 One bright spot in the quest for early detection of lung cancer has been the results from the National Lung Cancer Screening Trial.2 This trial found that for people at high risk for lung cancer, defined as being 55 to 74 years of age, current smoker or having achieved smoking cessation within the past 15 years, and having at least a 30 pack-year smoking history, there was a 20% relative reduction in mortality from lung cancer with the use of annual LDCT screening compared with annual chest x-ray scans for detection of lung cancer. This difference in mortality could be a result of identifying earlier stages of lung cancer in the LDCT group. Thus, this preventive screening test, the LDCT lung screen, could lead to earlier diagnosis, more timely medical intervention, and, ultimately, better outcomes for patients with lung cancer.
Because of these promising results, the LDCT lung screening program for high-risk patients began in 2013. High-risk patients were defined by using a version of the inclusion criteria derived from the National Comprehensive Cancer Network (NCCN) in 2012.3 Briefly, the LDCT eligibility criteria within our organization were comparable to the NCCN guidelines with the exception that patients must be 50, not 55, years of age to be eligible for our program. These are similar to but not exactly the same as guidelines adopted by the Centers for Medicare & Medicaid Services (CMS) for reimbursement.4 This fact is important because our program started prior to Medicare reimbursement for scans, so some patients had to pay out of pocket for their tests.
A number of studies have documented the important role LDCT plays in lung cancer diagnosis, although they list some inherent problems as well, such as increased number of false-positive scans.5,6 Only a few studies have investigated streamlining the work flow for obtaining an LDCT scan. One such Danish study of processes for timely CT scans in patients with early lung cancer found that patients with symptoms of lung cancer had a significantly shorter median interval to scans than those with localized disease.7 Patient navigation was not involved in this process. They found the median primary care interval (initial presentation to primary care until referral to secondary care) in another arm of this study was 7 days (interquartile interval [IQI], 0-30 days), and the median diagnostic interval (time from first presentation until diagnosis) was 39 days (IQI, 17-93 days).8 The median interval from order to scan in the present study was comparable to the second Danish study, although the patient population in the current study has much more variability.
Since initiation of the program in 2013, the patient navigator who facilitated the screening process identified multiple barriers that delayed screening. The issues identified included provider education, the referral process, financial considerations, follow-up protocols, and streamlining of LDCT scheduling. One major obstacle identified was the process in place for scheduling the scan, which frequently required multiple phone calls to the patient and radiology. This process was cumbersome, took a lot of time on the part of the patient navigator, and in some instances delayed the LDCT screening appointment for up to 3 weeks after the order was received by the patient navigator because of missed phone calls from the navigator to the patient. In this current manuscript, the identification of the barrier and our solution to removing it will be discussed.
The original process of scheduling LDCT lung screens was structured so that patients were identified by their physicians as eligible for the screening. Once these patients were identified as eligible, the LDCT scan order and demographic information were sent to patient navigation for a second confirmation of eligibility and coordination of the LDCT screen, as shown in Figure 1. In the initial LDCT screening process, the navigator received the order faxed from the physician’s office and then called the patient to confirm inclusion criteria were met for screening. Once patient eligibility was determined, several date and time preferences were obtained from the patient and coordinated unilaterally with the radiology department for scheduling. Figure 1 illustrates this process. Patient navigators were chosen to facilitate this process because, along with a secondary evaluation of patient eligibility, other programs were explained and offered to the patients, such as smoking cessation classes. This cumbersome process required multiple steps to arrange the date of the scan, often consisting of multiple calls to the patient and radiology to get an appointment scheduled. Due to the back and forth between patient navigator and patient and radiology, there was a delay in service that resulted in increased patient noncompliance. This lack of compliance was due to a decreased sense of urgency for the patient to receive the screening as time from his or her physician’s appointment lapsed.
After working with the screening procedure outlined on the left half of Figure 1, opportunities to improve and streamline the flow, thus shortening the time between the scan order and the scan, were identified. Therefore, a multidisciplinary team consisting of patient navigators, medical directors, radiologists, and billing specialists collaborated to determine the best way to improve LDCT scheduling efficiency for patients.
Beginning November 1, 2014, a new method was implemented that simplified this step in the scheduling process with the goal of decreasing the time between receipt of the physician’s order for the LDCT lung screen and the date of the actual screening. This new process involved a 3-way conference call between the patient, navigator, and radiology scheduler for more prompt, efficient scheduling. This change in the work flow meant that although the patient navigator was still facilitating the process, this was all done in 1 phone call. It cut out the back and forth between navigator and patient, and navigator and radiology. Figure 1 shows the comparison of the previous process versus the new, improved process.
Patients were included in the study if they met all criteria and followed through with the scheduling processes. Patients were excluded from analysis for noncompliance, declination of the service, or not meeting inclusion criteria for the screening. Data collected included a patient’s date of birth, sex, race/ethnicity, and the inclusion/exclusion information used to determine eligibility. Dates of receipt of the LDCT lung screen order from the medical provider and date of procedure were also collected to calculate time lapse between dates. Data were grouped by receipt of LDCT order preimplementation and postimplementation of the new process, as of November 1, 2014. Because some patients received a subsequent LDCT lung scan per the NCCN guidelines for follow-up, only data from a patient’s first scan were included in the analysis.
Comparison of days lapsed between order and actual scan preintervention and postintervention was analyzed using the Wilcoxon/Kruskal-Wallis rank sum tests because the data were not normally distributed. We wanted to determine if age affected the days lapsed from the order to the scan because there was a significant difference in age between the 2 groups. Therefore, a regression analysis was performed to determine if there was a significant relationship between age and days lapsed from the order to scan.
Since its inception, 111 patients have undergone preventive LDCT screening through the program with a total of 145 scans (92 before and 53 after the change in process). Two patients, a married couple, were excluded from the analysis due to planned travel between the initiation of the order and the actual scan, causing an outlier in the data. Only the first scan for each patient was included for our analysis, which resulted in data from 109 patients. We only included the first scan because 28 patients had multiple scans, and 20 of these patients had scans before and after the change in protocol. Of these 109 patients included in the analysis, 54 were male and 55 were female patients. One hundred patients were non-Hispanic white (91.7%), followed by African American (5; 4.6%), Hispanic (3; 2.8%), and Asian (1; 0.9%; Table 1). There was no significant difference between preintervention and postintervention in gender or race. There was a significant difference in age, with patients in the preintervention group being older (64.8 vs 62.0 years of age; P = .0451; Figure 2), but this age difference was not related to days lapsed between order and scan (P = .1201). Table 1 shows the demographic information of patients included in the study.
The time between receipt of the LDCT lung screen order and the date of the actual scan was reduced by 3 days preintervention versus postintervention (13.5 vs 10.1 days, respectively; Table 2). The median number of days from order to scan was 7 for the preintervention group and 5.5 for the postintervention group, but this difference was not statistically significant (Figure 3; P = .2953).
At the time of data analysis, the times between receipt of LDCT lung screen order and the date of the actual scan were not statistically significant for the 2 groups. However, the data were trending toward shorter lag times from order to date of actual scan postintervention. Due to the unequal patient numbers (79 patients preintervention vs 30 patients postintervention), it is postulated that as the sample size increases in the postintervention group over time, the difference between the groups will continue to widen, yielding more timely screenings and follow-up per the NCCN guidelines.
There is strong evidence that early detection of lung cancer yields better outcome for patients. With the recent CMS determination of Medicare coverage for the screening in February 2015,4 the LDCT lung screen has become more accessible to the population, increasing the importance of an efficient screening program that allows timely screening and appropriate follow-up for patients.
This scheduling process improvement is imperative in leading to earlier diagnosis, follow-up, and medical intervention when appropriate, as well as increasing accessibility of the screenings to patients at high risk for lung cancer. In one recent nationwide study of planning and implementing LDCT lung cancer screening programs in the United States, it was found that barriers included not enough demand from patients and few physician referrals for the scans. The main barriers included by representatives from 65 Lung Cancer Alliance Screening Centers of Excellence were reimbursement from insurance, costs associated with the program, as well as physician knowledge to increase referrals.9 This group cited the importance of a multidisciplinary team to approach problems encountered in the screening program.9 Similar results were found in another high-volume LDCT program started in a major metropolitan area.10 The authors found insurance issues and education of local primary care physician networks to be 2 major impediments to lung screening. Efforts for work flow improvement persist as the multidisciplinary team continues to strive toward expedited patient access to timely and efficient LDCT lung screening and earlier diagnosis of lung cancer.
- American Cancer Society. Cancer Facts & Figures 2015. Atlanta, GA: American Cancer Society; 2015.
- National Lung Screening Trial Research Team; Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.
- Wood DE, Eapen GA, Ettinger DS, et al. Lung cancer screening. J Natl Compr Canc Netw. 2012;10:240-265.
- Centers for Medicare & Medicaid Services. National coverage determination (NCD) for lung cancer screening with low dose computed tomography (LDCT) (210.14). www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=364&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&. 2015. Accessed May 9, 2016.
- Mulshine JL, D’Amico TA. Issues with implementing a high-quality lung cancer screening program. CA Cancer J Clin. 2014;64:352-363.
- Eberth JM. Lung cancer screening with low-dose CT in the United States. J Am Coll Radiol. 2015;12(12 Pt B):1395-1402.
- Guldbrandt LM, Fenger-Grøn M, Rasmussen TR, et al. The role of general practice in routes to diagnosis of lung cancer in Denmark: a population-based study of general practice involvement, diagnostic activity and diagnostic intervals. BMC Health Serv Res. 2015;15:21.
- Guldbrandt LM, Fenger-Grøn M, Rasmussen TR, et al. The effect of direct access to CT scan in early lung cancer detection: an unblinded, cluster-randomised trial. BMC Cancer. 2015;15:934.
- Qiu R, Copeland A, Sercy E, et al. Planning and implementation of low-dose computed tomography lung cancer screening programs in the United States. Clin J Oncol Nurs. 2016;20:52-58.
- McKee BJ, McKee AB, Flacke S, et al. Initial experience with a free, high-volume, low-dose CT lung cancer screening program. J Am Coll Radiol. 2013;10:586-592.