Rationale: Achieving the net benefit of lung cancer screening (LCS) depends on optimizing patient selection. Objective: To identify factors associated with clinician assessments that a patient was unlikely to benefit from LCS ("LCS-inappropriate") because of comorbidities or limited life expectancy. Methods: Retrospective analysis of patients assessed for LCS at 30 Veterans Health Administration facilities from January 1, 2015 to February 1, 2021. We conducted hierarchical mixed-effects logistic regression analyses to determine factors associated with clinicians' designations of LCS inappropriateness (primary outcome), accounting for 3-year predicted probability (i.e., competing risk) of non-lung cancer death. Measurements and Main Results: Among 38,487 LCS-eligible patients, 1,671 (4.3%) were deemed LCS-inappropriate by clinicians, whereas 4,383 (11.4%) had an estimated 3-year competing risk of non-lung cancer death greater than 20%. Patients with higher competing risks of non-lung cancer death were more likely to be deemed LCS-inappropriate (odds ratio [OR], 2.66; 95% confidence interval [CI], 2.32-3.05). Older patients (ages 75-80; OR, 1.45; 95% CI, 1.18-1.78) and those with interstitial lung disease (OR, 1.98; 95% CI, 1.51-2.59) were more likely to be deemed LCS-inappropriate than would be explained by competing risk of non-lung cancer death, whereas patients currently smoking (OR, 0.65; 95% CI, 0.58-0.73) were less likely to be deemed LCS-inappropriate, suggesting that clinicians over- or underweighted these factors. The probability of being deemed LCS-inappropriate varied from 0.4% to 74%, depending on the clinician making the assessment (median OR, 3.07; 95% CI, 2.89-3.25). Conclusion: Concerningly, the likelihood that a patient is deemed LCS-inappropriate is more strongly associated with the clinician making the assessment than with patient characteristics. Patient selection may be optimized by providing decision support to help clinicians assess net LCS benefit.

PURPOSE Lung cancer screening (LCS) has less benefit and greater potential for iatrogenic harm among people with multiple comorbidities and limited life expectancy. Yet, such individuals are more likely to undergo screening than healthier LCS-eligible people. We sought to understand how patients with marginal LCS benefit conceptualize their health and make decisions regarding LCS. METHODS We interviewed 40 people with multimorbidity and limited life expectancy, as determined by high Care Assessment Need scores, which predict 1 -year risk of hospitalization or death. Patients were recruited from 6 Veterans Health Administration facilities after discussing LCS with their clinician. We conducted a thematic analysis using constant comparison to explore factors that influence LCS decision making. RESULTS Patients commonly held positive beliefs about screening and perceived LCS to be noninvasive. When posed with hypothetical scenarios of limited benefit, patients emphasized the nonlongevity benefits of LCS (eg, peace of mind, planning for the future) and generally did not consider their health status or life expectancy when making decisions regarding LCS. Most patients were unaware of possible additional evaluations or treatment of screendetected findings, but when probed further, many expressed concerns about the potential need for multiple evaluations, referrals, or invasive procedures. CONCLUSIONS Patients in this study with multimorbidity and limited life expectancy were unaware of their greater risk of potential harm when accepting LCS. Given patient trust in clinician recommendations, it is important that clinicians engage patients with marginal LCS benefit in shared decision making, ensuring that their values of desiring more information about their health are weighed against potential harms from further evaluations.

Background The Veterans Health Administration (VA) recommends lung cancer screening (LCS), including shared decision making between clinicians and veteran patients. We sought to characterize 1) veteran conceptualization of lung cancer risk and 2) veteran and clinician accounts of shared decision-making discussions about LCS to assess whether they reflect veteran concerns. Methods We conducted qualitative interviews at 6 VA sites, with 48 clinicians and 34 veterans offered LCS in the previous 6 mo. We thematically analyzed transcripts, focusing on lung cancer risk perceptions, LCS decision making, and patient-clinician conversations. Results Three themes emerged. 1) Veterans’ lung cancer risk conceptualizations incorporated smoking, occupational hazards, and family history, whereas clinicians focused on smoking as the primary risk factor. 2) Veterans’ risk perceptions were influenced by symptoms, recency of exposures, and anecdotes about smoking, cancer, and lung disease, leading some veterans to believe other risk factors outweighed smoking in increasing lung cancer risk. 3) Both veterans and clinicians described LCS conversations centered on smoking, with little mention of other risks. Limitations Our findings may not reflect non-VA settings; for example, veterans may be more concerned about airborne hazards. Conclusions While airborne hazards strongly influenced veterans’ lung cancer risk conceptualizations, clinicians seldom addressed this risk factor during LCS shared decision making, instead focusing on smoking. Implications In 2022, the US Congress highlighted the link between military toxic exposures and lung cancer risk, requiring VA clinicians to discuss these exposures and conferring automatic VA benefits to exposed veterans with cancer. There is a time-sensitive need for tools to support VA clinicians in discussing military hazards as a lung cancer risk factor, which may result in more engaging, less stigmatizing LCS shared decision-making conversations. Highlights Veterans’ conceptualizations of their lung cancer risk were multifactorial and sometimes ranked exposure to occupational airborne hazards and family history above smoking in increasing lung cancer risk. However, patient-clinician lung cancer screening (LCS) conversations were typically brief and focused on smoking, which could stigmatize patients and failed to engage veterans in discussing what mattered most to them in thinking about their lung cancer risk. These findings are of heightened importance in light of the 2022 Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act, which requires VA clinicians to discuss toxic military exposures and their relationship to lung cancer and other health conditions. Tools that help clinicians assess and incorporate multiple risk factors into discussions about lung cancer may better address patients’ concerns and beliefs and lead to more engaging, less stigmatizing shared decision-making conversations about LCS.

Background Primary care providers (PCPs) are often the first point of contact for discussing lung cancer screening (LCS) with patients. While guidelines recommend against screening people with limited life expectancy (LLE) who are less likely to benefit, these patients are regularly referred for LCS. Objective We sought to understand barriers PCPs face to incorporating life expectancy into LCS decision-making for patients who otherwise meet eligibility criteria, and how a hypothetical point-of-care tool could support patient selection. Design Qualitative study based on semi-structured telephone interviews. Participants Thirty-one PCPs who refer patients for LCS, from six Veterans Health Administration facilities. Approach We thematically analyzed interviews to understand how PCPs incorporated life expectancy into LCS decision-making and PCPs’ receptivity to a point-of-care tool to support patient selection. Final themes were organized according to the Cabana et al. framework Why Don’t Physicians Follow Clinical Practice Guidelines , capturing the influence of clinician knowledge, attitudes, and behavior on LCS appropriateness determinations. Key Results PCP referrals to LCS for patients with LLE were influenced by limited knowledge of the life expectancy threshold at which patients are less likely to benefit from LCS, discomfort estimating life expectancy, fear of missing cancer at the point of early detection, and prioritization of factors such as quality of life, patient values, clinician-patient relationship, and family support. PCPs were receptive to a decision support tool to inform and communicate LCS appropriateness decisions if easy to use and integrated into clinical workflows. Conclusions Our study suggests knowledge gaps and attitudes may drive decisions to offer screening despite LLE, a behavior counter to guideline recommendations. Integrating a LCS decision support tool that incorporates life expectancy within the electronic medical record and existing clinical workflows may be one acceptable solution to improve guideline concordance and increase confidence in selecting high benefit patients for LCS.

ObjectiveTo examine how lung cancer screening (LCS) is coordinated across healthcare systems, specifically Veterans Affairs (VA) and non-VA settings.Data Sources and Study SettingWe conducted primary qualitative data collection in six VA medical centers with established LCS programs from November 2020 to November 2021.Study Design and Data Collection MethodsSemi-structured interviews were conducted with 48 primary care providers, LCS program coordinators and directors, and pulmonologists. Thematic analysis examined spontaneously raised narratives related to initiating and coordinating LCS for Veterans screened in non-VA settings. We mapped coordination challenges to each step of the LCS care continuum.Principal FindingsWhile non-VA options increased access to LCS for Veterans, VA medical centers lacked clear processes for initiating LCS referrals and tracking Veterans across the LCS continuum when screening occurred in non-VA settings. The responsibility of coordinating LCS with community providers often fell to VA primary care providers rather than LCS programs. Gaps in communication and data transfer contributed to delayed evaluation of potentially cancerous nodules post-screening, raising concerns about compromised care quality when LCS was shared with non-VA settings.ConclusionsWhile policies expanding LCS for Veterans in non-VA settings increase access, lack of consistent processes to initiate referrals, obtain results, and promote timely downstream evaluation fragmented care and delayed evaluation of concerning nodules. These unintended consequences highlight a need to address cross-system coordination challenges. Strategies to better coordinate LCS between VA and non-VA settings are essential to achieve high quality LCS and prevent Veterans from falling through the cracks.

Background: Telemedicine is an important option for rural older adults who often must travel far distances to clinics or forgoessential care. In 2014, the Geriatric Research, Education, and Clinical Centers (GRECC) of the US Veterans Health Administration(VA) established a national telemedicine network called GRECC Connect. This network increased access to geriatric specialtycare for the 1.4 million rural VA-enrolled veterans aged 65 years or older. The use of telemedicine skyrocketed during theCOVID-19 pandemic, which disproportionately impacted older adults, exacerbating disparities in specialty care access asoverburdened systems shut down in-person services. This surge presented a unique opportunity to study the supports necessaryfor those who would forgo telemedicine if in-person care were available. Objective: In spring 2021, we interviewed veterans and their informal caregivers to (1) elicit their experiences attempting toprepare for a video visit with a GRECC Connect geriatric specialist and (2) explore facilitators and barriers to successful engagementin a telemedicine visit. Methods: We conducted a cross-sectional qualitative evaluation with patients and their caregivers who agreed to participate inat least 1 GRECC Connect telemedicine visit in the previous 3 months. A total of 30 participants from 6 geographically diverseGRECC Connect hub sites agreed to participate. Semistructured interviews were conducted through telephone or the VA'svideoconference platform for home telemedicine visits (VA Video Connect) per participant preference. We observed challengesand, when needed, provided real-time technical support to facilitate VA Video Connect use for interviews. All interviews wererecorded with permission and professionally transcribed. A team of 5 researchers experienced in qualitative research analyzedinterview transcripts using rapid qualitative analysis. Results: From 30 participant interviews, we identified the following 4 categories of supports participants described regardingsuccessful engagement in telemedicine, as defined by visit completion, satisfaction, and willingness to engage in telemedicine in the future: (1) caregiver presence to facilitate technology setup and communication; (2) flexibility in visit modality (eg, videofrom home or a clinic or telephone); (3) technology support (eg, determining device compatibility or providing instruction andon-demand assistance); and (4) assurance of comfort with web-based communication, including orientation to features like closedcaptioning. Supports were needed at multiple points before the visit, and participants stressed the importance of eliciting thevarying needs and preferences of each patient-caregiver dyad. Though many initially agreed to a telemedicine visit because ofpandemic-related clinic closures, participants were satisfied with telemedicine and willing to use it for other types of health carevisits

Background Telemedicine is an important option for rural older adults who often must travel far distances to clinics or forgo essential care. In 2014, the Geriatric Research, Education, and Clinical Centers (GRECC) of the US Veterans Health Administration (VA) established a national telemedicine network called GRECC Connect. This network increased access to geriatric specialty care for the 1.4 million rural VA-enrolled veterans aged 65 years or older. The use of telemedicine skyrocketed during the COVID-19 pandemic, which disproportionately impacted older adults, exacerbating disparities in specialty care access as overburdened systems shut down in-person services. This surge presented a unique opportunity to study the supports necessary for those who would forgo telemedicine if in-person care were available. Objective In spring 2021, we interviewed veterans and their informal caregivers to (1) elicit their experiences attempting to prepare for a video visit with a GRECC Connect geriatric specialist and (2) explore facilitators and barriers to successful engagement in a telemedicine visit. Methods We conducted a cross-sectional qualitative evaluation with patients and their caregivers who agreed to participate in at least 1 GRECC Connect telemedicine visit in the previous 3 months. A total of 30 participants from 6 geographically diverse GRECC Connect hub sites agreed to participate. Semistructured interviews were conducted through telephone or the VA’s videoconference platform for home telemedicine visits (VA Video Connect) per participant preference. We observed challenges and, when needed, provided real-time technical support to facilitate VA Video Connect use for interviews. All interviews were recorded with permission and professionally transcribed. A team of 5 researchers experienced in qualitative research analyzed interview transcripts using rapid qualitative analysis. Results From 30 participant interviews, we identified the following 4 categories of supports participants described regarding successful engagement in telemedicine, as defined by visit completion, satisfaction, and willingness to engage in telemedicine in the future: (1) caregiver presence to facilitate technology setup and communication; (2) flexibility in visit modality (eg, video from home or a clinic or telephone); (3) technology support (eg, determining device compatibility or providing instruction and on-demand assistance); and (4) assurance of comfort with web-based communication, including orientation to features like closed captioning. Supports were needed at multiple points before the visit, and participants stressed the importance of eliciting the varying needs and preferences of each patient-caregiver dyad. Though many initially agreed to a telemedicine visit because of pandemic-related clinic closures, participants were satisfied with telemedicine and willing to use it for other types of health care visits. Conclusions To close gaps in telemedicine use among rural older adults, supports must be tailored to individuals, accounting for technology availability and comfort, as well as availability of and need for caregiver involvement. Comprehensive scaffolding of support starts well before the first telemedicine visit.

BackgroundQualitative health services research often relies on semistructured or in-depth interviews to develop a deeper understanding of patient experiences, motivations, and perspectives. The quality of data gathered is contingent upon a patient’s recall capacity; yet, studies have shown that recall of medical information is low. Threats to generating rich and detailed interview data may be more prevalent when interviewing older adults. ObjectiveWe developed and studied the feasibility of using a tool, Remembering Healthcare Encounters Visually and Interactively (REVISIT), which has been created to aid the recall of a specific telemedicine encounter to provide health services research teams with a visual tool, to improve qualitative interviews with older adults. MethodsThe REVISIT visual appointment summary was developed to facilitate web-based interviews with our participants as part of an evaluation of a geriatric telemedicine program. Our primary aims were to aid participant recall, maintain focus on the index visit, and establish a shared understanding of the visit between participants and interviewers. The authors’ experiences and observations developing REVISIT and using it during videoconference interviews (N=16) were systematically documented and synthesized. We discuss these experiences with REVISIT and suggest considerations for broader implementation and future research to expand upon this preliminary work. ResultsREVISIT enhanced the interview process by providing a focus and catalyst for discussion and supporting rapport-building with participants. REVISIT appeared to support older patients’ and caregivers’ recollection of a clinical visit, helping them to share additional details about their experience. REVISIT was difficult to read for some participants, however, and could not be used for phone interviews. ConclusionsREVISIT is a promising tool to enhance the quality of data collected during interviews with older, rural adults and caregivers about a health care encounter. This novel tool may aid recall of health care experiences for those groups for whom it may be more challenging to collect accurate, rich qualitative data (eg, those with cognitive impairment or complex medical care), allowing health services research to include more diverse patient experiences.

AbstractObjectiveExplore the perceived benefits of a Veterans Health Administration (VHA) geriatric specialty telemedicine service (GRECC Connect) among rural, older patients and caregivers to contribute to an assessment of its quality and value.Data SourcesIn Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits.Study DesignA cross‐sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges.Data CollectionWe conducted 30 semi‐structured qualitative interviews with rural, older (≥65) patients enrolled in the VHA and their caregivers via videoconference or phone. Interviews were recorded, transcribed, and analyzed using a rapid qualitative analysis approach.Principal FindingsParticipants described geriatric specialty telemedicine visits focused on cognitive assessments, tailored physical therapy, medication management, education on disease progression, support for managing multiple comorbidities, and suggestions to improve physical functioning. Participants reported that, in addition to prescribing medications and ordering tests, clinicians expedited referrals, coordinated care, and listened to and validated both patient and caregiver concerns. Perceived benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow‐up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age‐Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi‐complexity).ConclusionsAlignment of patient and caregiver experiences with widely‐used models of comprehensive geriatric care indicates that high‐quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.

Several studies have shown involvement of peroxynitrite anion, a potent oxidative agent, in Alzheimer's disease (AD) neuropathology. Herein, we assessed in platelets and erythrocytes of AD patients, age-matched and young adults controls: thiobarbituric acid-reactive substances (TBARS) production; superoxide dismutase (SOD), nitric oxide synthase (NOS) and Na,K-ATPase activities; cyclic GMP (cGMP) content, both basal and after sodium nitroprusside (SNP) stimulation. Aging was associated with an increase in TBARS production and NOS activity, a decrease in basal cGMP content and no change in SOD and Na,K-ATPase activities. AD patients, compared to aged controls, have: increase in TBARS production and in NOS, SOD and Na,K-ATPase activities but no alteration in basal cGMP content. SNP increased cGMP platelets production in all groups. In conclusion, we demonstrated in platelets and erythrocytes a disruption in systemic modulation of oxidative stress in aging and with more intensity in AD.

Abstract Telemedicine is critical to extending healthcare’s reach to rural older adults with complex medical needs, yet concerns remain about feasibility and acceptability for this population and their caregivers. We interviewed 30 rural Veterans ≥65 years old and/or their caregivers (n=21) about their experiences with video or telephone visits as part of an evaluation of Virtual Geriatrics, a network of Veterans Affairs tele-geriatric care hubs. Interviews were recorded, transcribed, and analyzed using rapid qualitative analysis. Caregivers deemed telemedicine a convenient option that prevented burdensome travel to remote specialists, facilitated caregiver involvement in visits, and matched quality of in-person visits. Caregivers often managed technology, enabling their loved one to participate in video visits. Telephone visits, while convenient, sometimes caused missed physical cues and hearing challenges which led providers to lean on caregiver communication. Our findings suggest telemedicine is feasible and acceptable for delivery for geriatrics care among rural adults and their caregivers.

BACKGROUND:Little is known about rates of invasive procedures and associated complications after lung cancer screening (LCS) in nontrial settings. RESEARCH QUESTION:What are the frequency of invasive procedures, complication rates, and factors associated with complications in a national sample of veterans screened for lung cancer? STUDY DESIGN AND METHODS:We conducted a retrospective cohort analysis of veterans who underwent LCS in any Veterans Health Administration (VA) facility between 2013 and 2019 and identified veterans who underwent invasive procedures within 10 months of initial LCS. The primary outcome was presence of a complication within 10 days after an invasive procedure. We conducted hierarchical mixed-effects logistic regression analyses to determine patient- and facility-level factors associated with complications resulting from an invasive procedure. RESULTS:Our cohort of 82,641 veterans who underwent LCS was older, more racially diverse, and had more comorbidities than National Lung Screening Trial (NLST) participants. Overall, 1,741 veterans (2.1%) underwent an invasive procedure after initial screening, including 856 (42.3%) bronchoscopies, 490 (24.2%) transthoracic needle biopsies, and 423 (20.9%) thoracic surgeries. Among veterans who underwent procedures, 151 (8.7%) experienced a major complication (eg, respiratory failure, prolonged hospitalization) and an additional 203 (11.7%) experienced an intermediate complication (eg, pneumothorax, pleural effusion). Veterans who underwent thoracic surgery (OR, 7.70; 95% CI, 5.48-10.81), underwent multiple nonsurgical procedures (OR, 1.49; 95% CI, 1.15-1.92), or carried a dementia diagnosis (OR, 3.91; 95% CI, 1.79-8.52) were more likely to experience complications. Invasive procedures were performed less often than in the NLST (2.1% vs 4.2%), but veterans were more likely to experience complications after each type of procedure. INTERPRETATION:These findings may reflect a higher threshold to perform procedures in veteran populations with multiple comorbidities and higher risks of complications. Future work should focus on optimizing the identification of patients whose chance of benefit likely outweighs the complication risks.

Studies show uneven access to Medicare-approved lung cancer screening (LCS) programs across the United States. The Veterans Health Administration (VA), the largest national US integrated health system, is potentially well positioned to coordinate LCS services across regional units to ensure that access matches distribution of need nationally.To what extent does LCS access (considering both VA and partner sites) and use match the distribution of eligible Veterans at state and regional levels?In this retrospective analysis, we identified LCS examinations in VA facilities between 2013 and 2019 from the VA Corporate Data Warehouse and plotted VA facilities with LCS geographically. We compared estimated LCS rates (unique Veterans screened per LCS-eligible population) across states and VA regional units. Finally, we assessed whether the VA's new partnership with the GO2 Foundation for Lung Cancer (which includes more than 750 LCS centers) closes geographic gaps in LCS access.We identified 71,898 LCS examinations in 96 of 139 (69.1%) VA facilities in 44 states between 2013 and 2019, with substantial variation across states (0-8 VA LCS facilities per state). Screening rates among eligible Veterans in the population varied more than 30-fold across regional networks (rate ratio, 33.6; 95% CI, 30.8-36.7 for VA New England vs Veterans Integrated Service Network 4), with weak correlation between eligible populations and LCS rates (coefficient, -0.30). Partnering with the GO2 Foundation for Lung Cancer expands capacity and access (eg, all states now have ≥ 1 VA or partner LCS site), but 9 of the 12 states with the highest proportions of rural Veterans still have ≤ 3 total LCS facilities.Disparities in LCS access exist based on where Veterans live, particularly for rural Veterans, even after partnering with the GO2 Foundation for Lung Cancer. The nationally integrated VA system has an opportunity to leverage regional resources to distribute and coordinate LCS services better to ensure equitable access.

TOPIC: Lung Cancer TYPE: Original Investigations PURPOSE: Lung cancer screening (LCS) guidelines recommend shared decision-making (SDM) to review the risks and benefits of screening, but little is known about patient factors associated with decisions to decline vs accept LCS. We leveraged a national cohort of Veterans offered LCS to characterize first, how often Veterans decline LCS after a SDM discussion, and second, what patient clinical and demographic factors are associated with declining LCS. Our hypothesis was that Veterans with cardiopulmonary and mental health comorbid conditions would be more likely to decline LCS. METHODS: This was a retrospective study of Veterans eligible for LCS between 2013-2021 who had a clinical reminder completed in the VA electronic health record to indicate the presence of clinician offered LCS in a SDM discussion. We used administrative data from the VA’s Corporate Data Warehouse to identify clinical reminder responses (i.e., accept vs decline LCS), Veteran demographics and comorbidities. The primary outcome was the presence of a clinical reminder documenting a Veteran as declining LCS. We conducted hierarchical mixed effects logistic regression analyses, with VA facilities as random effects, to determine factors associated with declining LCS. RESULTS: Overall, there were 30,577 Veterans eligible for LCS of which 20,757 (67.9%) agreed to screen while 9,820 (32.1%) declined screening after undergoing SDM. Veterans were more likely to agree to screen if they were younger (ages 55-64), racially Black (OR 0.77, 95% CI 0.71-0.82), ethnically Hispanic (OR 0.64, 95% CI 0.52-0.78), had more frequent outpatient visits or received their care at an academic facility (OR 0.69, 95%CI 0.65-0.72). Veterans were more likely to decline screening if they lived in rural zip codes (OR 1.11, 95% CI 1.05-1.16), had spent more days in long-term care facilities, had a history of congestive heart failure (OR 1.26, 95% IC 1.15-1.39), schizophrenia (OR 1.69, 95% CI 1.47-1.94), or higher Elixhauser Comorbidity Index (OR 1.03, 95% CI 1.02-1.04). There were no differences in odds of declining LCS among Veterans with Chronic Obstructive Pulmonary Disease, current smokers or those with lower income. CONCLUSIONS: Older Veterans with serious comorbidities, who may have competing health demands that make LCS a lower priority, were more likely to decline LCS. Importantly, Black Veterans were receptive to LCS, suggesting an avenue to address long-standing disparities in lung cancer. By contrast, rural Veterans, who also experience worse lung cancer outcomes, were less likely to agree to LCS. CLINICAL IMPLICATIONS: Further action is needed to address barriers to LCS uptake and adherence among underserved populations to avoid exacerbating existing disparities. DISCLOSURES: No relevant relationships by Jacqueline Boudreau, source=Web Response No relevant relationships by Tanner Caverly, source=Web Response No relevant relationships by Mark Glickman, source=Web Response no disclosure on file for Donald Miller; No relevant relationships by Eduardo Nunez, source=Web Response No relevant relationships by Shirley Qian, source=Web Response No relevant relationships by Renda Wiener, source=Web Response No relevant relationships by Sanqian Zhang, source=Web Response

BACKGROUND: Studies show uneven access to Medicare-approved lung cancer screening (LCS) programs across the United States. The Veterans Health Administration (VA), the largest national US integrated health system, is potentially well positioned to coordinate LCS services across regional units to ensure that access matches distribution of need nationally. RESEARCH QUESTION: To what extent does LCS access (considering both VA and partner sites) and use match the distribution of eligible Veterans at state and regional levels? METHODS: In this retrospective analysis, we identified LCS examinations in VA facilities between 2013 and 2019 from the VA Corporate Data Warehouse and plotted VA facilities with LCS geographically. We compared estimated LCS rates (unique Veterans screened per LCS-eligible population) across states and VA regional units. Finally, we assessed whether the VA's new partnership with the GO(2) Foundation for Lung Cancer (which includes more than 750 LCS centers) closes geographic gaps in LCS access. RESULTS: We identified 71,898 LCS examinations in 96 of 139 (69.1%) VA facilities in 44 states between 2013 and 2019, with substantial variation across states (0-8 VA LCS facilities per state). Screening rates among eligible Veterans in the population varied more than 30-fold across regional networks (rate ratio, 33.6; 95% CI, 30.8-36.7 for VA New England vs Veterans Integrated Service Network 4), with weak correlation between eligible populations and LCS rates (coefficient, -0.30). Partnering with the GO(2) Foundation for Lung Cancer expands capacity and access (eg, all states now have >= 1 VA or partner LCS site), but 9 of the 12 states with the highest proportions of rural Veterans still have <= 3 total LCS facilities. INTERPRETATION: Disparities in LCS access exist based on where Veterans live, particularly for rural Veterans, even after partnering with the GO(2) Foundation for Lung Cancer. The nationally integrated VA system has an opportunity to leverage regional resources to distribute and coordinate LCS services better to ensure equitable access.

Importance:Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs. Objective:To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up. Design, Setting, and Participants:This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020. Main Outcomes and Measures:Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims. Results:Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions. Conclusions and Relevance:In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.