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Adherence to Lung Cancer Screening in a Veterans Population Using Centralized and Decentralized Approaches
BACKGROUND
Implementation of lung cancer screening (LCS) in high-risk individuals reduces the risk of dying from lung cancer. The mortality benefit of LCS, however, can only be fully actualized in patients who adhere to follow-up screening examinations. Question: Does a centralized program offer better adherence to lung cancer screening compared with a decentralized approach?
METHODS
A retrospective analysis of a large Veterans Affairs medical center LCS program was conducted to compare adherence to follow-up screening in veterans established through the consult-based (centralized) program with those screened by primary care providers (decentralized). In addition, imaging referral rates from the centralized program were longitudinally reviewed and compared. The cohort included patients completing an LCS imaging examination between 10/2020 and 1/2022. Annual adherence was assessed in patients with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2 and was defined as returning for follow-up imaging within 15 months. Outcomes among patients undergoing screening using a centralized and decentralized approach were compared using a two-proportion z-test.
RESULTS
A total of 1,114 patients with a baseline Lung-RADS score of 1 or 2 were included. The amount of low-dose CT (LDCT) imaging ordered for LCS increased exponentially from 2021 to 2023; however, a higher percentage of LDCT examinations were ordered via the decentralized approach, with no significant change observed over time (76%, 71%, and 74% in 2021, 2022, and 2023, respectively). Overall adherence was 42%. Within the centralized program, adherence was 74% compared to 34% using a decentralized approach (p <0.001).
IMPLICATIONS
Adherence to annual screening among eligible veterans is greater within a centralized program. Future research aimed at identifying barriers and maximizing adherence to LCS is needed.
BACKGROUND
Implementation of lung cancer screening (LCS) in high-risk individuals reduces the risk of dying from lung cancer. The mortality benefit of LCS, however, can only be fully actualized in patients who adhere to follow-up screening examinations. Question: Does a centralized program offer better adherence to lung cancer screening compared with a decentralized approach?
METHODS
A retrospective analysis of a large Veterans Affairs medical center LCS program was conducted to compare adherence to follow-up screening in veterans established through the consult-based (centralized) program with those screened by primary care providers (decentralized). In addition, imaging referral rates from the centralized program were longitudinally reviewed and compared. The cohort included patients completing an LCS imaging examination between 10/2020 and 1/2022. Annual adherence was assessed in patients with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2 and was defined as returning for follow-up imaging within 15 months. Outcomes among patients undergoing screening using a centralized and decentralized approach were compared using a two-proportion z-test.
RESULTS
A total of 1,114 patients with a baseline Lung-RADS score of 1 or 2 were included. The amount of low-dose CT (LDCT) imaging ordered for LCS increased exponentially from 2021 to 2023; however, a higher percentage of LDCT examinations were ordered via the decentralized approach, with no significant change observed over time (76%, 71%, and 74% in 2021, 2022, and 2023, respectively). Overall adherence was 42%. Within the centralized program, adherence was 74% compared to 34% using a decentralized approach (p <0.001).
IMPLICATIONS
Adherence to annual screening among eligible veterans is greater within a centralized program. Future research aimed at identifying barriers and maximizing adherence to LCS is needed.
BACKGROUND
Implementation of lung cancer screening (LCS) in high-risk individuals reduces the risk of dying from lung cancer. The mortality benefit of LCS, however, can only be fully actualized in patients who adhere to follow-up screening examinations. Question: Does a centralized program offer better adherence to lung cancer screening compared with a decentralized approach?
METHODS
A retrospective analysis of a large Veterans Affairs medical center LCS program was conducted to compare adherence to follow-up screening in veterans established through the consult-based (centralized) program with those screened by primary care providers (decentralized). In addition, imaging referral rates from the centralized program were longitudinally reviewed and compared. The cohort included patients completing an LCS imaging examination between 10/2020 and 1/2022. Annual adherence was assessed in patients with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2 and was defined as returning for follow-up imaging within 15 months. Outcomes among patients undergoing screening using a centralized and decentralized approach were compared using a two-proportion z-test.
RESULTS
A total of 1,114 patients with a baseline Lung-RADS score of 1 or 2 were included. The amount of low-dose CT (LDCT) imaging ordered for LCS increased exponentially from 2021 to 2023; however, a higher percentage of LDCT examinations were ordered via the decentralized approach, with no significant change observed over time (76%, 71%, and 74% in 2021, 2022, and 2023, respectively). Overall adherence was 42%. Within the centralized program, adherence was 74% compared to 34% using a decentralized approach (p <0.001).
IMPLICATIONS
Adherence to annual screening among eligible veterans is greater within a centralized program. Future research aimed at identifying barriers and maximizing adherence to LCS is needed.
Pembrolizumab Dose Conversion Adoption and Immune-Mediated Adverse Events
Background/Purpose
On April 28, 2020, the Food and Drug Administration approved pembrolizumab 400mg intravenous (IV) every 6 weeks. This dosing update was rapidly adopted by VA Northeast Ohio Healthcare System (VANEOHS) hematology/oncology providers to minimize infusion appointments, for patient convenience and COVID precautions. On May 1, 2020, pembrolizumab order set templates were updated to reflect the extended interval dosing, however providers are still able to change orders to 200mg IV every 3 weeks if needed. Due to administration of higher pembrolizumab doses, there could be increased development of immune-mediated adverse events (IrAEs). This review quantified the clinic visits saved at VANEOHS by adoption of pembrolizumab 400mg dosing and report adverse events that resulted in pembrolizumab dose reduction.
Methods
A report of all pembrolizumab orders from May 1, 2020 to May 1, 2021 was obtained. All pembrolizumab 200mg orders were reviewed to evaluate reasoning for the use of the 200mg dose. A retrospective chart review was performed for patients who required a pembrolizumab dose reduction to evaluate safety. Descriptive statistics were used.
Results
There was a total of 277 pembrolizumab orders from May 1, 2020 to May 1, 2021. Of these orders, 211 (76%) were converted to pembrolizumab 400mg IV every 6 weeks, while 66 (24%) orders remained at pembrolizumab 200mg IV every 3 weeks. It is estimated that there were 211 infusion appointments avoided due to the conversion to pembrolizumab 400mg IV every 6-week dosing. The 277 pembrolizumab orders were used to treat 77 unique patients. Eighteen patients continued to receive pembrolizumab 200mg following the conversion. Sixteen of these patients were maintained on pembrolizumab 200mg due to concomitant chemotherapy schedules. One patient was receiving pembrolizumab 200mg based on clinical trial dosing. One patient returned to pembrolizumab 200mg due to an increase in drainage from pleurx catheter while receiving 400mg dose.
Implications
The conversion from pembrolizumab 200mg every 3 weeks to pembrolizumab 400mg every 6 weeks avoided approximately 200 infusion appointments without an increase in safety concerns. This supporting data may aid in supporting extended interval dosing of other immunotherapy agents.
Background/Purpose
On April 28, 2020, the Food and Drug Administration approved pembrolizumab 400mg intravenous (IV) every 6 weeks. This dosing update was rapidly adopted by VA Northeast Ohio Healthcare System (VANEOHS) hematology/oncology providers to minimize infusion appointments, for patient convenience and COVID precautions. On May 1, 2020, pembrolizumab order set templates were updated to reflect the extended interval dosing, however providers are still able to change orders to 200mg IV every 3 weeks if needed. Due to administration of higher pembrolizumab doses, there could be increased development of immune-mediated adverse events (IrAEs). This review quantified the clinic visits saved at VANEOHS by adoption of pembrolizumab 400mg dosing and report adverse events that resulted in pembrolizumab dose reduction.
Methods
A report of all pembrolizumab orders from May 1, 2020 to May 1, 2021 was obtained. All pembrolizumab 200mg orders were reviewed to evaluate reasoning for the use of the 200mg dose. A retrospective chart review was performed for patients who required a pembrolizumab dose reduction to evaluate safety. Descriptive statistics were used.
Results
There was a total of 277 pembrolizumab orders from May 1, 2020 to May 1, 2021. Of these orders, 211 (76%) were converted to pembrolizumab 400mg IV every 6 weeks, while 66 (24%) orders remained at pembrolizumab 200mg IV every 3 weeks. It is estimated that there were 211 infusion appointments avoided due to the conversion to pembrolizumab 400mg IV every 6-week dosing. The 277 pembrolizumab orders were used to treat 77 unique patients. Eighteen patients continued to receive pembrolizumab 200mg following the conversion. Sixteen of these patients were maintained on pembrolizumab 200mg due to concomitant chemotherapy schedules. One patient was receiving pembrolizumab 200mg based on clinical trial dosing. One patient returned to pembrolizumab 200mg due to an increase in drainage from pleurx catheter while receiving 400mg dose.
Implications
The conversion from pembrolizumab 200mg every 3 weeks to pembrolizumab 400mg every 6 weeks avoided approximately 200 infusion appointments without an increase in safety concerns. This supporting data may aid in supporting extended interval dosing of other immunotherapy agents.
Background/Purpose
On April 28, 2020, the Food and Drug Administration approved pembrolizumab 400mg intravenous (IV) every 6 weeks. This dosing update was rapidly adopted by VA Northeast Ohio Healthcare System (VANEOHS) hematology/oncology providers to minimize infusion appointments, for patient convenience and COVID precautions. On May 1, 2020, pembrolizumab order set templates were updated to reflect the extended interval dosing, however providers are still able to change orders to 200mg IV every 3 weeks if needed. Due to administration of higher pembrolizumab doses, there could be increased development of immune-mediated adverse events (IrAEs). This review quantified the clinic visits saved at VANEOHS by adoption of pembrolizumab 400mg dosing and report adverse events that resulted in pembrolizumab dose reduction.
Methods
A report of all pembrolizumab orders from May 1, 2020 to May 1, 2021 was obtained. All pembrolizumab 200mg orders were reviewed to evaluate reasoning for the use of the 200mg dose. A retrospective chart review was performed for patients who required a pembrolizumab dose reduction to evaluate safety. Descriptive statistics were used.
Results
There was a total of 277 pembrolizumab orders from May 1, 2020 to May 1, 2021. Of these orders, 211 (76%) were converted to pembrolizumab 400mg IV every 6 weeks, while 66 (24%) orders remained at pembrolizumab 200mg IV every 3 weeks. It is estimated that there were 211 infusion appointments avoided due to the conversion to pembrolizumab 400mg IV every 6-week dosing. The 277 pembrolizumab orders were used to treat 77 unique patients. Eighteen patients continued to receive pembrolizumab 200mg following the conversion. Sixteen of these patients were maintained on pembrolizumab 200mg due to concomitant chemotherapy schedules. One patient was receiving pembrolizumab 200mg based on clinical trial dosing. One patient returned to pembrolizumab 200mg due to an increase in drainage from pleurx catheter while receiving 400mg dose.
Implications
The conversion from pembrolizumab 200mg every 3 weeks to pembrolizumab 400mg every 6 weeks avoided approximately 200 infusion appointments without an increase in safety concerns. This supporting data may aid in supporting extended interval dosing of other immunotherapy agents.