Lung Cancer Screening Before and After a Multifaceted Electronic Health Record Intervention
Authors: Kukhareva Polina V. , Li Haojia , Caverly Tanner J. , Fagerlin Angela , Del Fiol Guilherme , Hess Rachel , Zhang Yue , Butler Jorie M. , Schlechter Chelsey , Flynn Michael C. , Reddy Chakravarthy , Choi Joshua , Balbin Christian , Warner Isaac A. , Warner Phillip B. , Nanjo Claude , Kawamoto, Kensaku 
Published: June 2024

Importance

Lung cancer is the deadliest cancer in the US. Early-stage lung cancer detection with lung cancer screening (LCS) through low-dose computed tomography (LDCT) improves outcomes.

Objective

To assess the association of a multifaceted clinical decision support intervention with rates of identification and completion of recommended LCS-related services.

Design, Setting, and Participants

This nonrandomized controlled trial used an interrupted time series design, including 3 study periods from August 24, 2019, to April 27, 2022: baseline (12 months), period 1 (11 months), and period 2 (9 months). Outcome changes were reported as shifts in the outcome level at the beginning of each period and changes in monthly trend (ie, slope). The study was conducted at primary care and pulmonary clinics at a health care system headquartered in Salt Lake City, Utah, among patients aged 55 to 80 years who had smoked 30 pack-years or more and were current smokers or had quit smoking in the past 15 years. Data were analyzed from September 2023 through February 2024.

Interventions

Interventions in period 1 included clinician-facing preventive care reminders, an electronic health record–integrated shared decision-making tool, and narrative LCS guidance provided in the LDCT ordering screen. Interventions in period 2 included the same clinician-facing interventions and patient-facing reminders for LCS discussion and LCS.

Main Outcome and Measure

The primary outcome was LCS care gap closure, defined as the identification and completion of recommended care services. LCS care gap closure could be achieved through LDCT completion, other chest CT completion, or LCS shared decision-making.

Results

The study included 1865 patients (median [IQR] age, 64 [60-70] years; 759 female [40.7%]). The clinician-facing intervention (period 1) was not associated with changes in level but was associated with an increase in slope of 2.6 percentage points (95% CI, 2.4-2.7 percentage points) per month in care gap closure through any means and 1.6 percentage points (95% CI, 1.4-1.8 percentage points) per month in closure through LDCT. In period 2, introduction of patient-facing reminders was associated with an immediate increase in care gap closure (2.3 percentage points; 95% CI, 1.0-3.6 percentage points) and closure through LDCT (2.4 percentage points; 95% CI, 0.9-3.9 percentage points) but was not associated with an increase in slope. The overall care gap closure rate was 175 of 1104 patients (15.9%) at the end of the baseline period vs 588 of 1255 patients (46.9%) at the end of period 2.

Conclusions and Relevance

In this study, a multifaceted intervention was associated with an improvement in LCS care gap closure.

Trial Registration

ClinicalTrials.gov Identifier: NCT04498052