OIG Finds ‘Inconsistent’ Lung Cancer Screening at VA Facilities

Early diagnosis improves lung cancer survival. Yet in the general population, only 17% of cases are diagnosed at an early stage. Among veterans, that rises to more than 30%.

Despite the impact lung cancer screening (LCS) has on improving survival, screening rates in the US remain low. In November 2017, the US Department of Veterans Affairs (VA) issued a memorandum providing recommendations for LCS with low-dose computer tomography (CT) scans at VA facilities. The memorandum was updated July 2022. While the Office of the Inspector General (OIG) called the memoranda “guidelines,” it also stipulated to VA facilities that they may “only” perform LCS when they meet all 10 mandatory elements:  

• Standardized, evidence-based criteria for eligibility, frequency, and duration of LCS
• Processes to facilitate the identification of patients who meet VA LCS eligibility criteria
• Patient education materials and shared decision making for patients regarding participation in an LCS program
• Clinical LCS coordinator(s) to coordinate the care and management of patients in the program
• Access to an effective, evidence-based smoking cessation program
• An LCS program oversight board responsible for oversight of the program’s conduct and management
• Access to a multidisciplinary lung nodule management board with clinical expertise in lung nodule management and diagnostic pathways
• Access to a tumor board with expertise in lung cancer treatment
• Optimized radiology CT protocols and standardized procedure names, along with standardized reporting methodology/codes and lung nodule management guidelines
• A patient management tool/registry to rigorously track and manage patients to ensure high levels of adherence to LCS management guidelines

However, in a recent investigation, the OIG found that facility staff involved in LCS reported that VA LCS guideline requirements “presented barriers to broader adoption of LCS” and did not ensure consistent implementation.

One problem, the OIG found, was the limited use of LCS at VA facilities. Just over half of the surveyed VA facilities reported having an established LCS program consistent with VA guidelines for LCS in 2022. There were also barriers to implementing LCS program requirements, such as the absence of an LCS coordinator, the lack of adequate staffing, the absence of a patient registry, and the lack of a multidisciplinary board.

Another problem was the inconsistent implementation of screening. Facilities with LCS programs reported varied use of program elements, including inconsistent use of an LCS coordinator to manage patients in the program.

The OIG also found that regardless of whether facilities had established an adherent LCS program, they varied in how they identified screening-eligible patients. The VA National Center for LCS recommends the use of clinical reminders as the preferred method to identify patients—but it is not required and not all facilities use it. The clinical reminder, the OIG report points out, can capture accurate smoking history information within the electronic health record to support identifying patients meeting LCS criteria.

The facilities also varied in their methods for interpreting low-dose CT scans. Ten sites, for instance, reported not using an established system for the classification of the results. The OIG notes that this could lead to inaccurate interpretation of the low-dose CT scan results and increase the risk for patient harm and health care costs.

The OIG made the following 3 recommendations to the Under Secretary for Health: (1) Review the operational memorandum for lung cancer screening implementation and assess whether LCS rates could be enhanced by allowing a facility to conduct LCS while developing all mandated elements; (2) Review the operational memorandum for LCS implementation and assess whether LCS rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements; and (3) Consider mandating eligible patients be offered LCS consistent with other required cancer screenings in the VA.

The Under Secretary for Health concurred with the recommendations and provided an acceptable action plan. The OIG will follow up on the planned actions until they are completed.

Early diagnosis improves lung cancer survival. Yet in the general population, only 17% of cases are diagnosed at an early stage. Among veterans, that rises to more than 30%.

Despite the impact lung cancer screening (LCS) has on improving survival, screening rates in the US remain low. In November 2017, the US Department of Veterans Affairs (VA) issued a memorandum providing recommendations for LCS with low-dose computer tomography (CT) scans at VA facilities. The memorandum was updated July 2022. While the Office of the Inspector General (OIG) called the memoranda “guidelines,” it also stipulated to VA facilities that they may “only” perform LCS when they meet all 10 mandatory elements:  

• Standardized, evidence-based criteria for eligibility, frequency, and duration of LCS
• Processes to facilitate the identification of patients who meet VA LCS eligibility criteria
• Patient education materials and shared decision making for patients regarding participation in an LCS program
• Clinical LCS coordinator(s) to coordinate the care and management of patients in the program
• Access to an effective, evidence-based smoking cessation program
• An LCS program oversight board responsible for oversight of the program’s conduct and management
• Access to a multidisciplinary lung nodule management board with clinical expertise in lung nodule management and diagnostic pathways
• Access to a tumor board with expertise in lung cancer treatment
• Optimized radiology CT protocols and standardized procedure names, along with standardized reporting methodology/codes and lung nodule management guidelines
• A patient management tool/registry to rigorously track and manage patients to ensure high levels of adherence to LCS management guidelines

However, in a recent investigation, the OIG found that facility staff involved in LCS reported that VA LCS guideline requirements “presented barriers to broader adoption of LCS” and did not ensure consistent implementation.

One problem, the OIG found, was the limited use of LCS at VA facilities. Just over half of the surveyed VA facilities reported having an established LCS program consistent with VA guidelines for LCS in 2022. There were also barriers to implementing LCS program requirements, such as the absence of an LCS coordinator, the lack of adequate staffing, the absence of a patient registry, and the lack of a multidisciplinary board.

Another problem was the inconsistent implementation of screening. Facilities with LCS programs reported varied use of program elements, including inconsistent use of an LCS coordinator to manage patients in the program.

The OIG also found that regardless of whether facilities had established an adherent LCS program, they varied in how they identified screening-eligible patients. The VA National Center for LCS recommends the use of clinical reminders as the preferred method to identify patients—but it is not required and not all facilities use it. The clinical reminder, the OIG report points out, can capture accurate smoking history information within the electronic health record to support identifying patients meeting LCS criteria.

The facilities also varied in their methods for interpreting low-dose CT scans. Ten sites, for instance, reported not using an established system for the classification of the results. The OIG notes that this could lead to inaccurate interpretation of the low-dose CT scan results and increase the risk for patient harm and health care costs.

The OIG made the following 3 recommendations to the Under Secretary for Health: (1) Review the operational memorandum for lung cancer screening implementation and assess whether LCS rates could be enhanced by allowing a facility to conduct LCS while developing all mandated elements; (2) Review the operational memorandum for LCS implementation and assess whether LCS rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements; and (3) Consider mandating eligible patients be offered LCS consistent with other required cancer screenings in the VA.

The Under Secretary for Health concurred with the recommendations and provided an acceptable action plan. The OIG will follow up on the planned actions until they are completed.

Early diagnosis improves lung cancer survival. Yet in the general population, only 17% of cases are diagnosed at an early stage. Among veterans, that rises to more than 30%.

Despite the impact lung cancer screening (LCS) has on improving survival, screening rates in the US remain low. In November 2017, the US Department of Veterans Affairs (VA) issued a memorandum providing recommendations for LCS with low-dose computer tomography (CT) scans at VA facilities. The memorandum was updated July 2022. While the Office of the Inspector General (OIG) called the memoranda “guidelines,” it also stipulated to VA facilities that they may “only” perform LCS when they meet all 10 mandatory elements:  

• Standardized, evidence-based criteria for eligibility, frequency, and duration of LCS
• Processes to facilitate the identification of patients who meet VA LCS eligibility criteria
• Patient education materials and shared decision making for patients regarding participation in an LCS program
• Clinical LCS coordinator(s) to coordinate the care and management of patients in the program
• Access to an effective, evidence-based smoking cessation program
• An LCS program oversight board responsible for oversight of the program’s conduct and management
• Access to a multidisciplinary lung nodule management board with clinical expertise in lung nodule management and diagnostic pathways
• Access to a tumor board with expertise in lung cancer treatment
• Optimized radiology CT protocols and standardized procedure names, along with standardized reporting methodology/codes and lung nodule management guidelines
• A patient management tool/registry to rigorously track and manage patients to ensure high levels of adherence to LCS management guidelines

However, in a recent investigation, the OIG found that facility staff involved in LCS reported that VA LCS guideline requirements “presented barriers to broader adoption of LCS” and did not ensure consistent implementation.

One problem, the OIG found, was the limited use of LCS at VA facilities. Just over half of the surveyed VA facilities reported having an established LCS program consistent with VA guidelines for LCS in 2022. There were also barriers to implementing LCS program requirements, such as the absence of an LCS coordinator, the lack of adequate staffing, the absence of a patient registry, and the lack of a multidisciplinary board.

Another problem was the inconsistent implementation of screening. Facilities with LCS programs reported varied use of program elements, including inconsistent use of an LCS coordinator to manage patients in the program.

The OIG also found that regardless of whether facilities had established an adherent LCS program, they varied in how they identified screening-eligible patients. The VA National Center for LCS recommends the use of clinical reminders as the preferred method to identify patients—but it is not required and not all facilities use it. The clinical reminder, the OIG report points out, can capture accurate smoking history information within the electronic health record to support identifying patients meeting LCS criteria.

The facilities also varied in their methods for interpreting low-dose CT scans. Ten sites, for instance, reported not using an established system for the classification of the results. The OIG notes that this could lead to inaccurate interpretation of the low-dose CT scan results and increase the risk for patient harm and health care costs.

The OIG made the following 3 recommendations to the Under Secretary for Health: (1) Review the operational memorandum for lung cancer screening implementation and assess whether LCS rates could be enhanced by allowing a facility to conduct LCS while developing all mandated elements; (2) Review the operational memorandum for LCS implementation and assess whether LCS rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements; and (3) Consider mandating eligible patients be offered LCS consistent with other required cancer screenings in the VA.

The Under Secretary for Health concurred with the recommendations and provided an acceptable action plan. The OIG will follow up on the planned actions until they are completed.