Introduction
Little is known about how clinicians make low-dose computed tomography lung cancer
screening decisions in practice. Investigators assessed the factors associated with
real-world decision making, hypothesizing that lung cancer risk and comorbidity would
not be associated with agreeing to or receiving screening. Though these factors are
key determinants of the benefit of lung cancer screening, they are often difficult
to incorporate into decisions without the aid of decision tools.
Methods
This was a retrospective cohort study of patients meeting current national eligibility
criteria and deemed appropriate candidates for lung cancer screening on the basis
of clinical reminders completed over a 2-year period (2013–2015) at 8 Department of
Veterans Affairs medical facilities. Multilevel mixed-effects logistic regression
models (conducted in 2019–2020) assessed predictors (age, sex, lung cancer risk, Charlson
Comorbidity Index, travel distance to facility, and central versus outlying decision-making
location) of primary outcomes of agreeing to and receiving lung cancer screening.
Results
Of 5,551 patients (mean age=67 years, 97% male, mean lung cancer risk=0.7%, mean Charlson
Comorbidity Index=1.14, median travel distance=24.2 miles), 3,720 (67%) agreed to
lung cancer screening and 2,398 (43%) received screening. Lung cancer risk and comorbidity
score were not strong predictors of agreeing to or receiving screening. Empirical
Bayes adjusted rates of agreeing to and receiving screening ranged from 22% to 84%
across facilities and from 19% to 85% across clinicians. A total of 33.7% of the variance
in agreeing to and 34.2% of the variance in receiving screening was associated with
the facility or the clinician offering screening.
Conclusions
Substantial variation was found in Veterans agreeing to and receiving lung cancer
screening during the Veterans Affairs Lung Cancer Screening Demonstration Project.
This variation was not explained by differences in key determinants of patient benefit,
whereas the facility and clinician advising the patient had a large impact on lung
cancer screening decisions.
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Article Info
Publication History
Published online: December 17, 2020
Identification
Copyright
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine.
