Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019

Abstract

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)

Addressing Lung Cancer Screening Disparities: What Does It Mean to Be Centralized?

“…This study is consistent with prior studies showing that Black individuals are less likely to receive an initial LCS, and when they do undergo LCS, they are about 30% less likely to receive the recommended follow-up ( 2 – 4 ). These are highly concerning findings as Black men have the highest lung cancer incidence and mortality from lung cancer of any demographic group ( 5 ), and Black populations may derive greater relative mortality benefits from screening ( 6 ).…”

Lung Cancer Diagnosed Through Screening, Lung Nodule, and Neither Program: A Prospective Observational Study of the Detecting Early Lung Cancer (DELUGE) in the Mississippi Delta Cohort

“…The programs reached different demographic segments of the population, potentially providing a means of overcoming the looming problem of access disparity to lung cancer screening, which threatens to widen racial, sex, and socioeconomic and geographic disparities in lung cancer mortality. [11][12][13][14][15][35][36][37][38][39][40][41][42] Despite evidence from two large randomized clinical trials that lung cancer screening saves lives, adoption has been slow, difficult, and complex, even in the United States where social policy moved in 2015 to provide payment for annual LDCT screening as part of standard health care coverage. 6,43 Barriers to implementation include the need for infrastructure for recruiting candidates who meet eligibility criteria for screening and conducting the mandated shared decision making and tobacco cessation counseling services required before the LDCT screening test can be performed.…”

Factors Associated With Declining Lung Cancer Screening After Discussion With a Clinician in a Cohort of US Veterans

“… 33 , 34 , 35 However, prior work has shown lower LCS rates among racial and ethnic minority groups and those with lower socioeconomic status, 7 , 8 and we previously found lower adherence to recommended follow-up after initiating LCS among Black veterans and those with lower income. 18 The current study adds to this literature by suggesting that disparities in LCS uptake and adherence may not be associated with screening hesitancy at the patient level but rather with structural barriers preventing receipt of equitable care. Our study found that overall, veterans with better access and connection to VHA care, as indicated by more VHA outpatient visits in the prior year, were more likely to accept LCS.…”

“…We selected clinically relevant covariables a priori based on prior studies of factors related to uptake of or adherence to LCS, including self-reported race and ethnicity to explore potential disparities in declining LCS. 18 , 19 , 20 , 21 , 22 , 23 For each veteran, we extracted data from the VA Corporate Data Warehouse on demographic characteristics and VA priority status (the VA’s system to determine co-payments). We used a veteran’s residential zip code to estimate median income, and we assessed urbanization using the US Census Bureau Rural-Urban Commuting Area codes.…”