Inaccuracies in electronic health records smoking data and a potential approach to address resulting underestimation in determining lung cancer screening eligibility

Abstract

Objective: The US Preventive Services Task Force (USPSTF) requires the estimation of lifetime pack-years to determine lung cancer screening eligibility. Leading electronic health record (EHR) vendors calculate pack-years using only the most recently recorded smoking data. The objective was to characterize EHR smoking data issues and to propose an approach to addressing these issues using longitudinal smoking data.

Materials and methods: In this cross-sectional study, we evaluated 16 874 current or former smokers who met USPSTF age criteria for screening (50-80 years old), had no prior lung cancer diagnosis, and were seen in 2020 at an academic health system using the Epic® EHR. We described and quantified issues in the smoking data. We then estimated how many additional potentially eligible patients could be identified using longitudinal data. The approach was verified through manual review of records from 100 subjects.

Results: Over 80% of evaluated records had inaccuracies, including missing packs-per-day or years-smoked (42.7%), outdated data (25.1%), missing years-quit (17.4%), and a recent change in packs-per-day resulting in inaccurate lifetime pack-years estimation (16.9%). Addressing these issues by using longitudinal data enabled the identification of 49.4% more patients potentially eligible for lung cancer screening (P < .001).

Discussion: Missing, outdated, and inaccurate smoking data in the EHR are important barriers to effective lung cancer screening. Data collection and analysis strategies that reflect changes in smoking habits over time could improve the identification of patients eligible for screening.

Conclusion: The use of longitudinal EHR smoking data could improve lung cancer screening.

Keywords: electronic health records; lung cancer screening; lung cancer screening eligibility; pack-years; self-reported smoking history.

Figure 1.

Smoking history collection form.

Figure 2.

Example of using Baseline and Longitudinal Approaches for patient who smoked 1 pack-per-day for 20 years and then switched to smoking 0.5 packs-per-day.

Figure 3.

Patient flow through inclusion and exclusion criteria.

Figure 4.

Diagram of patient eligibility for lung cancer screening according to the Baseline and Longitudinal Approaches.

Figure 5.

Number of eligible patients identified using Baseline and Longitudinal Approaches.

Figure 6.

Scatter plot of pack-years estimated using Baseline and Longitudinal Approaches for current smokers. The red line divides the plane in equal parts. The blue line represents the regression line between the pack-years estimated using 2 algorithms fitted by the local polynomial regression model. Forty-seven points are omitted due to pack-years estimated using either of the 2 algorithms larger than 100.