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 MEASURESReceipt 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 RELEVANCEIn 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 (continued)

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ImportanceLung cancer screening (LCS) is underused in the US, particularly in underserved populations, and little is known about factors associated with declining LCS. Guidelines call for shared decision-making when LCS is offered to ensure informed, patient-centered decisions.ObjectiveTo assess how frequently veterans decline LCS and examine factors associated with declining LCS.Design, Setting, and ParticipantsThis retrospective cohort study included LCS-eligible US veterans who were offered LCS between January 1, 2013, and February 1, 2021, by a physician at 1 of 30 Veterans Health Administration (VHA) facilities that routinely used electronic health record clinical reminders documenting LCS eligibility and veterans’ decisions to accept or decline LCS. Data were obtained from the Veterans Affairs (VA) Corporate Data Warehouse or Medicare claims files from the VA Information Resource Center.Main Outcomes and MeasuresThe main outcome was documentation, in clinical reminders, that veterans declined LCS after a discussion with a physician. Logistic regression analyses with physicians and facilities as random effects were used to assess factors associated with declining LCS compared with agreeing to LCS.ResultsOf 43 257 LCS-eligible veterans who were offered LCS (mean [SD] age, 64.7 [5.8] years), 95.9% were male, 84.2% were White, and 37.1% lived in a rural zip code; 32.0% declined screening. Veterans were less likely to decline LCS if they were younger (age 55-59 years: odds ratio [OR], 0.69; 95% CI, 0.64-0.74; age 60-64 years: OR, 0.80; 95% CI, 0.75-0.85), were Black (OR, 0.80; 95% CI, 0.73-0.87), were Hispanic (OR, 0.62; 95% CI, 0.49-0.78), did not have to make co-payments (OR, 0.92; 95% CI, 0.85-0.99), or had more frequent VHA health care utilization (outpatient: OR, 0.70; 95% CI, 0.67-0.72; emergency department: OR, 0.86; 95% CI, 0.80-0.92). Veterans were more likely to decline LCS if they were older (age 70-74 years: OR, 1.27; 95% CI, 1.19-1.37; age 75-80 years: OR, 1.93; 95% CI, 1.73-2.17), lived farther from a VHA screening facility (OR, 1.06; 95% CI, 1.03-1.08), had spent more days in long-term care (OR, 1.13; 95% CI, 1.07-1.19), had a higher Elixhauser Comorbidity Index score (OR, 1.04; 95% CI, 1.03-1.05), or had specific cardiovascular or mental health conditions (congestive heart failure: OR, 1.25; 95% CI, 1.12-1.39; stroke: OR, 1.14; 95% CI, 1.01-1.28; schizophrenia: OR, 1.87; 95% CI, 1.60-2.19). The physician and facility offering LCS accounted for 19% and 36% of the variation in declining LCS, respectively.Conclusions and RelevanceIn this cohort study, older veterans with serious comorbidities were more likely to decline LCS and Black and Hispanic veterans were more likely to accept it. Variation in LCS decisions was accounted for more by the facility and physician offering LCS than by patient factors. These findings suggest that shared decision-making conversations in which patients play a central role in guiding care may enhance patient-centered care and address disparities in LCS.