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Controlled Clinical Trial
. 2024 Jun 3;7(6):e2415383.
doi: 10.1001/jamanetworkopen.2024.15383.

Lung Cancer Screening Before and After a Multifaceted Electronic Health Record Intervention: A Nonrandomized Controlled Trial

Polina V Kukhareva  1 , Haojia Li  2 , Tanner J Caverly  3   4   5 , Angela Fagerlin  6   7 , Guilherme Del Fiol  1 , Rachel Hess  6   8 , Yue Zhang  2 , Jorie M Butler  1   8   9 , Chelsey Schlechter  6 , Michael C Flynn  8   10   11 , Chakravarthy Reddy  2 , Joshua Choi  1 , Christian Balbin  1 , Isaac A Warner  1 , Phillip B Warner  1 , Claude Nanjo  1 , Kensaku Kawamoto  1
Affiliations
Controlled Clinical Trial

Lung Cancer Screening Before and After a Multifaceted Electronic Health Record Intervention: A Nonrandomized Controlled Trial

Polina V Kukhareva et al. JAMA Netw Open. .

Abstract

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Drs Caverly and Fagerlin reported being co-creators of DecisionPrecision, a freely available and open-source tool to enable personalized shared decision-making for lung cancer screening. Dr Hess reported receiving grants from the National Institutes of Health during the conduct of the study and personal fees from the Astellas Pharmaceuticals data and safety monitoring board outside the submitted work. Dr Butler reported receiving consulting fees from the University of California, San Francisco, outside the submitted work. Dr Choi reported receiving grants from the National Library of Medicine during the conduct of the study. Dr Kawamoto reported receiving grants from Hitachi; personal fees from Pfizer, RTI International, the University of California at San Francisco, Indiana University, NORC at the University of Chicago, the University of Pennsylvania, Yale University, the Regenstrief Foundation, the Korean Society of Medical Informatics, the University of Nebraska, and the U.S. Office of the National Coordinator for Health Information Technology (via Security Risk Solutions); a book chapter honorarium from Elsevier; codevelopment from MD Aware; and licensing from Custom Clinical Decision Support outside the submitted work; serving as an unpaid board member of the nonprofit Health Level Seven International health information technology standard development organization and the US Health Information Technology Advisory Committee; and developing health information technology tools that may be commercialized to enable wider impact. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Shared Decision-Making App
A screenshot of the electronic health record (EHR)–integrated lung cancer screening SDM tool is presented. Numbers 1 to 4 refer to key features: identification of patients expected to have a high benefit (1), note generation (2), input autopopulation (3), and 1-click ordering (4). LDCT indicates low-dose computed tomography; green circles, lives saved by screening; red circles, lung cancer deaths; USPSTF, US Preventive Services Task Force.
Figure 2.
Figure 2.. Changes in Primary Outcomes
Lung cancer screening care gap closure through any means and low-dose computed tomography (LDCT)–based gap closure is presented overall (A) and by patient benefit level (B).
See this image and copyright information in PMC

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