Improving the implementation of lung cancer screening guidelines at UNC

DANIEL S . REULAND, MD, MPH

IHQI SEED GRANT SYMPOSIUM

MAY 24, 2016

Background•Lung cancer is the leading cause of cancer mortality in US

•Lung cancer screening with low dose computed tomography (LDCT) can reduce mortality

•Screening can also cause harms

•Annual screening recommended for high risk smokers

•Shared decision-making recommended (required by CMS)

Project Aims – Improve UNC’s capability to systematically•Identify potentially eligible population • Age 55-80 years, 30+ pack years, currently smoke or quit < 15 years ago

•Alert primary care providers to potentially eligible patients• Automated clinical reminder

•Support high quality informed/ shared decision making processes• Decision aid, shared decision making documentation, billing

•Interpret and report CT images in a standard way• Lung-RADS is a nodule classification system designed to standardize

reporting and follow-up

Dr. Ratner’s Experience•Recently saw a 62 year old patient with chronic medical problems not seen for over a year

•Dr. Ratner was alerted to consider offering lung cancer screening

•She deferred alert until the next visit when there was more time

•Next visit: shared decision making, documented & billed for counseling

•Patient chose to get screened, CT ordered & completed

•Lung-RADS 2 (benign appearance), recommendation to rescreen in one year

“The report was very clear. I think the patient was very satisfied, and the whole process was very easy for me.”

Getting there wasn’t easy

Screening process step

Patient Primary Care Team

Radiology Pulmonary/subspecialty

Potentially eligible patients identified

Full smoking history obtained

“Clinical eligibility” assessed

“Preference eligibility” assessed (shared decision making)

Chest CT ordered

CT Scan completed, interpreted & reported

Follow-up care (results dependent)

Screening process step

Patient Primary Care Team

Radiology Pulmonary/subspecialty

Potentially eligible patients identified

Full smoking history obtained

“Clinical eligibility” assessed

“Preference eligibility” assessed (shared decision making)

Chest CT ordered

CT Scan completed, interpreted & reported

Follow-up care (results dependent)

Screening process step

Patient Primary Care Team

Radiology Pulmonary/subspecialty

Potentially eligible patients identified

Full smoking history obtained

“Clinical eligibility” assessed

“Preference eligibility” assessed (shared decision making)

Chest CT ordered

CT Scan completed, interpreted & reported

Follow-up care (results dependent)

Gap: No systematic way to identify potentially eligible patients

Screening eligibility criteria

1. Ages 55-80 years

2. 30 or more pack-years (packs per day x years) of smoking*

3. Current smoker or, if former smoker, quit within past 15 years*

* not systematically collected or recorded in discrete fields in EHR

Systematic recording of smoking history

Tamrah Parker, MSN, RN, FNP-C – Clinic Nurse Manager

Collection of Smoking History

Improving collection of complete smoking history

Tested nurse protocol

Nurse training kickoff

Individual feedback

Weekly progress updates

Weekly winners’ board

Rewards for meeting goals

Flagging the appointment schedule (reminder)

Appointment Schedule Flagging

96 109 95 88 81 72 60 88 66 31 6 39 65 32 34 46 47 32 40 37 48 34 45 42 42 28 36 42 330%

10%

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90%

CompleteSmokingHistory Goal

Weekly completion rate for smoking histories for 55-80 year old patients seen in clinic

Kickoff Mtg. Chart Flagging Begins

Winners’ Board Added

Flagging Stopped

Flagging Resumed

Other BPA Activated

Nurse Reward Lunch

Flagging Stopped

Flagging Resumed

Cumulatively, 58% of current and former smokers age 55-80 seen since project start have had a complete smoking history assessed (894/1552)

Gap: No system for having providers systematically consider (or offer) screening for potentially eligible patients

Screening process step

Patient Primary Care Team

Radiology Pulmonary/subspecialty

Potentially eligible patients identified

Full smoking history obtained

“Clinical eligibility” assessed

“Preference eligibility” assessed (shared decision making)

Chest CT ordered

CT Scan completed, interpreted & reported

Follow-up care (results dependent)

Complete smoking histories trigger a clinical reminder (BPA)

Training & Testing the Clinical Reminder (BPA)

Training kickoff session at division meeting

Peer to peer training (academic detailing)

BPA active in Epic “playground” training environment

How did we do?

Elizabeth Greig, MD – Assistant Medical Director

Clinical reminder (BPA) utilization, before and after peer training (n=512)

11% 19% 71%22% 8% 70%0%

10%

20%

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100%

CompletedReminder DeferredReminder NoAction

NoTraining/Pre-Training Post-Training

Screening process step

Patient Primary Care Team

Radiology Pulmonary/subspecialty

Potentially eligible patients identified

Full smoking history obtained

“Clinical eligibility” assessed

“Preference eligibility” assessed (shared decision making)

Chest CT ordered

CT Scan completed, interpreted & reported

Follow-up care (results dependent)

Gap: No systematic approach to providing shared decision making

BENEFIT

•Mortality reduction (3-5 deaths averted per 1000 individuals screened)

HARMS

•False positives leading to invasive procedures (20-25 per 1000 individuals screened annually)

•Overdiagnosis

•Radiation (small)

•Anxiety

•Costs

Shared Decision Making

A collaborative process between patient and provider to make healthcare decisions together taking into account evidence, as well as patient values and preferences*

CMS requires a shared decision making visit (using a decision aid) before it will pay for lung cancer screening

*Informed Medical Decisions Foundation, 2016

Enhancing lung cancer screening shared decision-making

M. Patricia Rivera, MD, FCCP – Professor of Medicine, Pulmonary Diseases and Critical Care Medicine

Enhancing Shared Decision-MakingProvided infrastructure to support shared decision making and tobacco counseling (including documentation)

Linked brief decision aid to clinical reminder

Resident training

Guidance regarding billing for shared decision making visit

Screening process step

Patient Primary Care Team

Radiology Pulmonary/subspecialty

Potentially eligible patients identified

Full smoking history obtained

“Clinical eligibility” assessed

“Preference eligibility” assessed (shared decision making)

Chest CT ordered

CT Scan completed, interpreted & reported

Follow-up care (results dependent)

Gap: No standardized way to interpret and report CT images

Subspecialty Working Group for Lung Cancer Screening

Joined QI project with existing group piloting a research registry of lung cancer screening

Agreed on Lung-RADS based classification system

Worked with thoracic radiology to understand workflow and develop a dictation template

Screening CTs with Lung-RADS documented(average 23 CTs/quarter, increasing)

0% 0% 40% 92% 95% 93%0%

10%

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40%

50%

60%

70%

80%

90%

100%

Q12015(11) Q22015(14) Q32015(15) Q42015(26) Q12016(63) Q22016(14)

%WithLung-RADS

Screening CT findings at UNC

Lung-RADS Category % of CTscans

Follow-Up Plan

1 & 2 (benign appearance) 87% repeat in 1 year

3 (probably benign) 4% repeat in 6 months

4 (suspicious) 9% referral to MTOP

n=103 screening CTs

Lung-RADS streamlines follow up planning and care

Elizabeth Greig, MD – Assistant Medical Director

Spread Plan

Assess place among institutional priorities

Refine population-level management plan for abnormal CTs (nodules)

Health maintenance build in EPIC@UNC

Train nurses & providers

Turn on clinical reminder by practice

PDSA cycles within practices

Spread across PCIC with common metrics

Lessons LearnedImportance of crossing the continuum of care

Need to integrate informatics and best practices

High quality lung cancer screening program implementation limited by competing demands (payment model)

Acknowledgements

UNC Internal Medicine ClinicUNC Health Care Practice Quality and Innovation (PQI)Primary Care Improvement Collaborative (PCIC)R21 Registry Group