key: cord-0018896-cqt4e0uz
authors: Núñez, Eduardo R.; Caverly, Tanner J.; Zhang, Sanqian; Glickman, Mark E.; Qian, Shirley X.; Boudreau, Jacqueline H.; Slatore, Christopher G.; Miller, Donald R.; Wiener, Renda Soylemez
title: Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019
date: 2021-07-08
journal: JAMA Netw Open
DOI: 10.1001/jamanetworkopen.2021.16233
sha: 62461154bd61b37b974d61bf203be7de836a1c77
doc_id: 18896
cord_uid: cqt4e0uz

IMPORTANCE: Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs. OBJECTIVE: To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020. MAIN OUTCOMES AND MEASURES: Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims. RESULTS: Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions. CONCLUSIONS AND RELEVANCE: In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.

Procedure ICD-9 procedure codes ICD-10 procedure codes CPT procedure codes 32.20, 32.39, 32.3, 32.30, 32.39, 32.4, 32.41, 32.49, 32.5, 32.50, 32.59, 33.2, 33.20, 33.25, 33 .28, 0BBC4ZX 0BBD4ZX 0BBF4ZX 0BBG4ZX 0BBH4ZX 0BBJ4ZX 0BBK4ZX 0BBL4ZX 0BBM4ZX 0BDC4ZX 0BDD4ZX 0BDF4ZX 0BDG4ZX 0BDH4ZX 0BDJ4ZX 0BDK4ZX 0BDL4ZX, 0BBM0ZZ 0BBM3ZZ 0BBM7ZZ 0BTK4ZZ 0BTL4ZZ 0BTM4ZZ 0BBK4ZZ, 0BBL4ZZ, 0B5K0ZZ 0B5K3ZZ 0B5K7ZZ 0B5L0ZZ 0B5L3ZZ 0B5L7ZZ 0B5M0ZZ 0B5M3ZZ 0B5M7ZZ 0BBK0ZZ 0BBK3ZZ 0BBK7ZZ 0BBL0ZZ 0BBL3ZZ 0BBL7ZZ 0BTG0ZZ 0BTJ0ZZ, 0BB77ZZ 0BB80ZZ0BB83ZZ 0BB87ZZ 0BB90ZZ 0BB93ZZ 0BB97ZZ 0BBB0ZZ 0BBB3ZZ 0BBB7ZZ 0BTC4ZZ 0BTD4ZZ 0BTF4ZZ 0BTG4ZZ 0BTJ4ZZ 0BTC0ZZ 0BTD0ZZ 0BTF0ZZ , B5B0ZZ 0B5B3ZZ 0B5B7ZZ 0BB30ZZ 0BB33ZZ 0BB37ZZ 0BB40ZZ 0BB43ZZ 0BB47ZZ 0BB50ZZ 0BB53ZZ 0BB57ZZ 0BB60ZZ 0BB63ZZ 0BB67ZZ 0BB70ZZ 0BB73ZZ, 0B540ZZ 0B543ZZ 0B547ZZ 0B550ZZ 0B553ZZ 0B557ZZ 0B560ZZ 0B563ZZ 0B567ZZ 0B570ZZ 0B573ZZ 0B577ZZ 0B580ZZ 0B583ZZ 0B587ZZ 0B590ZZ 0B593ZZ 0B597ZZ 0BTG0ZZ, 0BTG0ZZ, 0BTJ0ZZ, 0BTK0ZZ, 0BTK0ZZ, 0BTL0ZZ, 0BTM0ZZ, 0B9L0ZX 0B9M0ZX 0BBK0ZX 0BBL0ZX 0BBM0ZX 0BB10ZZ 07JL0ZZ 07JM0ZZ 0WJ90ZZ 0WJB0ZZ 0WJQ0ZZ, 0BTK0ZZ, 0BTL0ZZ, 0BTM0ZZ, 0BTC0ZZ 0BTD0ZZ, 0BTF0ZZ, 0B930ZX 0B940ZX 0B950ZX 0B960ZX 0B970ZX 0B980ZX 0B990ZX 0B9B0ZX 0BB30ZX 0BB40ZX 0BB50ZX 0BB60ZX 0BB70ZX 0BB80ZX 0BB90ZX 0BBB0ZX 0B9K0ZX 0BDM4ZX 0B9C4ZX 0B9D4ZX 0B9F4ZX 0B9G4ZX 0B9H4ZX 0B9J4ZX 0B9K4ZX 0B9L4ZX 0B9M4ZX, 0BT30ZZ 0BT34ZZ 0BT40ZZ 0BT44ZZ 0BT50ZZ 0BT54ZZ 0BT60ZZ 0BT64ZZ 0BT70ZZ 0BT74ZZ 0BT80ZZ 0BT84ZZ 0BT90ZZ 0BT94ZZ 0BTB0ZZ 0B530ZZ 0B533ZZ 0B537ZZ 31786, 32095, 32100, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32500-32501, 32503-32504, 32520, 32602, 32657 

Lung Disease Congestive Heart Failure History of major adverse cardiac event Chronic kidney disease Dementia Depression Anxiety Post-traumatic stress disorder Schizophrenia Substance Use disorder Elixhauser Comorbidity Index, mean (SD)

Lung-RADS category (LungRADS-1 as reference)