Standardized Reporting and Management of Suspicious Findings on Chest CT Imaging Is Associated With Improved Lung Cancer Diagnosis in an Observational Study

BACKGROUND: Follow-up of chest CT scan ﬁ ndings suspicious for lung cancer may be delayed because of inadequate documentation. Standardized reporting and follow-up may reduce time to diagnosis and care for lung cancer. STUDY DESIGN AND METHODS: We implemented a reporting system that standardizes tagging of chest CT scan reports by classifying pulmonary ﬁ ndings. The system also automates referral of patients with ﬁ ndings suspicious for lung cancer to a multidisciplinary care team for rapid review and follow-up. The system was designed to reduce the time to diagnosis, particularly for early-stage lung cancer. We evaluated the effectiveness of this system, using a quasi-experimental stepped wedge cluster design, examining 99,148 patients who underwent diagnostic (nonscreening) chest CT imaging from 2015 to 2017 and who had not received a chest CT scan in the preceding 24 months. We evaluated the association of the intervention with the incidence of diagnosis and surgical treatment of early-stage (I, II) and late-stage (III, IV) lung cancer within 120 days of chest CT imaging. RESULTS: Forty percent of patients received the intervention. Among 2,856 patients (2.9%) who received diagnoses of lung cancer, 28% had early-stage disease. In multivariable analyses, the intervention was associated with 24% greater odds of early-stage diagnosis (OR, 1.24; 95% CI, 1.09-1.41) and no change in the odds of late-stage diagnosis (OR, 1.04; 95% CI, 0.95-1.14). The intervention was not associated with the rate of surgical treatment within 120 days. INTERPRETATION: In this large quasi-experimental community-based observational study, implementation of a system that combines standardized tagging of chest CT scan reports with clinical navigation was effective for increasing the diagnosis of early-stage lung cancer. 158(5):2211-2220 after implementation of the intervention, using an Aalen-Johansen estimator to account for competing risks due to death. 11 We used Cox proportional hazards regression with Fine and Gray competing risks to test the hypothesis that implementation of the reporting system was associated with pathologic diagnosis and surgical treatment. 12 Follow-up (in days) began on the date of the index CT scan and ended on the date of the outcome, health plan disenrollment, death, or follow-up end at 120 days, whichever occurred earliest. Hazard ratios (HRs) and 95% CIs were adjusted for 6-month time period, patient age, sex, race/ethnicity, Charlson Comorbidity Index, history of cancer, and smoking status. We accounted for clustering of patients by radiology center, using a working covariance and robust sandwich estimators to account for unknown covariance. Because analyses indicated that the proportional hazards assumption was violated for the association of the intervention with incidence of pathologic diagnosis, we estimated separate HRs for diagnosis within and more than 21 days after CT imaging. 13 These analyses were performed both for the overall population and for subgroups de ﬁ ned by disease stage.