PI: James S. Goodwin, MD
Project 1 is on screening for cancer. Its major new emphasis is on lung cancer screening with low dose CT (LDCT), recently approved by CMS and insurance companies. There are a number of concerns which impact the translation of an evidence-based preventive medicine activity into community practice. Prime among them for lung cancer screening is the potential harm done by invasive testing subsequent to false positive LDCTs, which might be higher in community practice than in the randomized controlled trials (RCT).
Another concern is that physicians may substitute routine diagnostic chest CTs for screening LDCT, analogous to what has occurred with screening colonoscopy. Use of a diagnostic lung CT code can circumvent the strict criteria established by CMS for reimbursement. If the CMS screening criteria are ignored, the risk/ benefit ratio is likely to be adversely altered. Our preliminary data demonstrate a substantial increase in the number of smokers receiving diagnostic lung CTs after publication of the LDCT trial in 2011.
A major question involves the implementation of the counseling/ shared decision making (SDM) visit mandated by CMS prior to LDCT screening. Who performs the SDM: the patient's PCP or the radiology facility? How is that process perceived by patients?
We will address those and related questions with two types of studies. First, we will systematically analyze Texas Medicare charge data from 2009-2019 in order to determine the patterns of counseling/ SDM and also receipt of LDCT lung cancer screening. We can examine how these patterns vary by patient characteristics. We can also assess false positive rates and downstream testing and how this varies by the radiology facility and physician network.
A second effort will be to design and implement a survey of patients who have undergone counseling/ SDM with or without subsequent LDCT screening, to explore their experience with SDM and LDCT screening. As a comparison we will also survey patients likely to qualify for LDCT screening but who had not yet received it.
These analyses will provide important information on false positive rates and subsequent testing as LDCT is implemented in the community, as well as the acceptance and effectiveness of the counseling/ SDM visit in informing patients about the benefits and risks of lung cancer screening.