Annual lung cancer screening (LCS) with low-dose computed tomography (LDCT) of the chest has been shown to reduce mortality rates for individuals at risk for lung cancer.1 Despite the benefits, < 5% of those who were eligible for LCS in the United States were screened in 2022.2 Implementation of a LCS program in rural communities is especially challenging because they are sparsely populated, medically underserved, and located far from urban centers.2-7 It is estimated that 1 in 5 people live in rural areas. Rates of tobacco smoking and cancer are higher in rural communities when compared with urban communities.8,9 The scarcity of physicians in rural areas who are familiar with LCS may further impede individuals who are at risk from accessing this life saving service.5,6 As a result, these individuals may not regularly undergo LCS as recommended.9
Telehealth, or the remote delivery of health care services via telecommunications, is an emerging approach for addressing unmet medical needs in rural communities and is being utilized widely by the US Department of Veterans Affairs (VA).4,10-15 The Veterans Integrated Service Network 12 (Great Lakes Network) has established the Clinical Resource Hub (CRH), a telehealth network comprising of licensed independent physicians, nurse practitioners, registered nurses, and ancillary staff. The CRH offers regular, remote health care services to several community-based outpatient clinics (CBOC) primary care clinics located in rural northern Wisconsin and the Upper Peninsula of Michigan.10,14
The utility of telehealth in promoting LCS among at-risk veterans living in rural communities has not been firmly established.4-6 To address this issue, we conducted a proof-of-principle quality improvement project to determine whether a telehealth intervention would increase referrals among at-risk veterans who reside in rural northern Wisconsin and the Upper Peninsula of Michigan who are self-enrolled in a CBOC smoking cessation program in Green Bay, Wisconsin. The CBOC provides primary health care to veterans residing in rural northern Wisconsin and the Upper Peninsula of Michigan as defined by US Department of Agriculture rural-urban commuting area codes.16 The intervention aimed to refer these individuals to the closest available and centralized LCS program, which is located at the Clement J. Zablocki VA Medical Center (CJZVAMC) in Milwaukee, Wisconsin.
METHODS
We reviewed electronic health records (EHR) of LCS-eligible veterans treated by 2 authors (SH and TB) who were self-enrolled in the smoking cessation program at the Green Bay CBOC between October 1, 2020, and September 30, 2021. The program provides comprehensive evidence-based tobacco use treatment, online self-help resources, behavioral counseling, and medicines for smoking cessation.17 Veterans aged 50 to 80 years with a smoking history of ≥ 20 pack-years, who currently smoke cigarettes or quit within the past 15 years, were considered at risk for lung cancer and eligible for LCS. After confirming eligibility, pertinent demographic data were abstracted from each EHR.
Telehealth Intervention
The CJZVAMC centralized LCS program manages all delivery processes and has been previously shown to increase uptake of LCS and improve patient outcomes among veterans as compared to a decentralized approach.18,19 In the centralized approach, eligible veterans were referred by a CBOC primary care practitioner (PCP) to a designated centralized LCS program. The centralized LCS program provides further evaluation and disposition, which includes structured and shared decision making, ordering LDCT of the chest, reporting LDCT results to the patient and PCP, devising a goal-directed care plan, and managing follow-up LDCTs as indicated (Figure 1).18,19
This intervention was initiated before other measures aimed to increase the LCS enrollment for at-risk rural veterans at the CBOC, (eg, mailing LCS education fact sheet to veterans).20 After reviewing prospective veterans’ EHRs, 1 author (TB) contacted LCS-eligible veterans by telephone and left a voicemail if contact could not be established. A second telephone call was placed within 2 months of the initial call if no call back was documented in the EHR. When verbal contact was established, the goals of the centralized LCS program were described and the veteran was invited to participate.21
Veterans were seen at CBOCs affiliated with CJZVAMC. The CJZVAMC LCS coordinator was notified whenever a veteran agreed to enroll into LCS and then ordered LDCT, which was performed and read at CJZVAMC. Once LDCT has been ordered, 1 author (TB) reviewed the veteran’s EHR for LDCT completion over the next 4 months.Upon conclusion of the intervention period, the number of veterans referred for LDCT and the number of LDCTs performed were recorded. Each LDCT was reviewed and coded by medical imaging clinicians according to Lung CT Screening Reporting and Data System (Lung-RADS) version 1.1 and coded as 0, 1, 2, 3, or 4 based on the nodule with the highest degree of suspicion.22 The LDCT and reports were also reviewed by pulmonary physicians at the CJZVAMC Lung Nodule Clinic with recommendations issued and reported to the PCP treating the veteran, such as annual follow-up with LDCT or referral to specialty care for further evaluation as indicated.