Improving community care lung cancer screening by implementation of centralized support: a quality improvement initiative

BACKGROUND: Lung cancer screening (LCS) is vital for early detection of lung cancer. Many veterans live in rural areas far from VA medical centers but may receive VA-funded care locally through care in the community (CITC). LCS through CITC may lack the centralized support available at main VA campuses, placing veterans at risk for lower-quality care. OBJECTIVES: We sought to determine: Does implementation of a centralized process for CITC LCS: reduce screening among ineligible individuals, improve timeliness of care and staff experience, decrease care fragmentation by recapturing imaging and consultative care within the VA, and increase appropriate imaging follow-up and specialty consultation for lung nodules identified through LCS? METHODS: We conducted a quality improvement initiative to incorporate centralized processes for veterans receiving LCS through CITC. A nurse coordinator served as implementation champion and was responsible for reviewing referrals, confirming eligibility for CITC and LCS, ensuring results were received back to the ordering medical center and ensuring follow-up was conducted according to Lung Imaging Reporting and Data System (LungRADS) guidelines. Quantitative data were compared pre- and post-implementation period for key outcomes (eligibility, timeliness, evaluation of high-risk nodules, care fragmentation). Qualitative data were obtained by interviewing participating staff. RESULTS: In the pre-implementation period, 6.3% (31/489) of patients who completed LCS were ineligible. In the post-implementation period, 14.3% (433/3023) of referred patients were ineligible, and 0 completed imaging. (P = .0001). The mean time between CT completion and results received by the ordering clinician or LCS coordinator decreased from 27.6 (19.7-35.5) days to 14.5 (9.3-19.8) days following program implementation (P = .0414), with improved guideline-adherent follow-up including serial imaging or pulmonary consult for high-risk nodules. More consults were completed at the VA (vs CITC) following program initiation (11.1% vs 88.0%, P = .0001). Participating staff felt the implementation process was smooth and were satisfied with the centralized support. CONCLUSION: Implementing a centralized LCS program for CITC patients resulted in improved guideline-adherent LCS, increased appropriate consultative care, decreased care fragmentation, and improved staff experience. Other VA healthcare systems should consider implementing similar centralized CITC-LCS programs.