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

Abstract

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.

Study rationale and design of the PEOPLHE trial

“…Identified barriers hampering LCS participation include travel issues or psychological factors (anxiety and stigma), which negatively impact a person’s motivation to attend [ 25 , 26 ]. Uptake and adherence disparities were potentially related to structural barriers preventing receipt of equitable care, lower socioeconomic status and difficulties in obtaining reimbursements [ 27 – 29 ].…”

Lung Cancer Screening Among U.S. Military Veterans by Health Status and Race and Ethnicity, 2017–2020: A Cross-Sectional Population-Based Study

“…The BRFSS survey question assessing LCS use does not differentiate between initial LDCT and subsequent scans, and different steps along the process of LCS may be associated with different barriers for patients. 20 , 53 Furthermore, the answer choices for self-rated health in the BRFSS (excellent/very good/good/fair/poor) differ somewhat from those used by NELSON investigators because they excluded individuals with moderate or bad self-rated health, and the question that ascertained difficulty in climbing stairs also asked about difficulty in walking in general.…”

“…Previous analyses in the Veterans Health Administration (VHA), 17 which serves approximately 49% of veterans, 18 , 19 have shown increased acceptance of screening among Black and Hispanic veterans after being offered LCS but also increased risk of delayed or no follow-up after initial LDCT scans among Black veterans. 20 …”

The Patient Protection and Affordable Care Act and Pediatric Medical Clinicians’ Application of Fluoride Varnish

“…Strategies recommended to overcome these barriers include providing training to all practice staff, identifying a staff member to champion this service, and having clear roles about who is responsible for ordering supplies and applying fluoride varnish . Additionally, prior research on preventive services has found that clinician recommendation is one of the strongest predictors of patient receipt of these services in adult populations . This has also been shown in pediatric populations, especially related to routine vaccines.…”