Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019.
Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019.
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DOI：
10.1001/jamanetworkopen.2021.16233
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发表时间：
2021-07-01
影响因子：
13.8
通讯作者：
Wiener RS
中科院分区：
文献类型：
--
作者：
Núñez ER;Caverly TJ;Zhang S;Glickman ME;Qian SX;Boudreau JH;Slatore CG;Miller DR;Wiener RS
在退伍军人健康管理局进行初次肺癌筛查后，哪些因素与坚持推荐的检测相关？在这项对28294名退伍军人进行的回顾性队列研究中，超过四分之一的退伍军人接受了延迟或没有随访检测。风险较高的退伍军人和高容量或学术中心的退伍军人更有可能得到及时的随访，而黑人退伍军人，患有精神健康疾病的退伍军人和收入较低的退伍军人更有可能推迟或缺席随访。这些研究结果表明，即使在一个综合的医疗保健系统，坚持肺癌筛查的不公平现象仍然存在。这项队列研究检查了美国退伍军人肺癌筛查后对随访检测建议的依从性。肺癌筛查（LCS）可以通过密切随访和遵守管理建议来降低肺癌死亡率。在现实世界的实践中，与LCS依从性相关的因素知之甚少，数据仅限于选定LCS项目的病例系列。根据国家队列标准化随访建议分析随访依从性，并确定与延迟或缺失随访相关的因素。这项回顾性队列研究是在美国退伍军人健康管理局（VHA）机构进行的。退伍军人在2015年至2019年期间接受了肺癌筛查，并有足够的随访时间接受推荐的评估。进行了患者和机构水平的logistic回归分析。分析了2019年11月26日至2020年12月16日的数据。根据肺部CT筛查报告和数据系统（Lung-RADS）类别，在初始LCS后接受建议的下一步，如VHA或Medicare索赔中所述。28294名退伍军人（26，835名[94.8%]男性; 21，969人[77.6%]是白色;平均[标准差]年龄，65.2 [5.5]岁）进行初始LCS检查，17863名退伍军人（63.1%）在预期时间内接受了推荐的随访，而3696名退伍军人（13.1%）进行了后期评估，4439名退伍军人（15.7%）没有明显的评估。设施水平的差异与9.2%的观察到的变化率迟或缺席评价。在多变量调整模型中，（比值比[OR]，1.19 [95% CI，1.10 - 1.29]），退伍军人创伤后应激障碍（OR，1.13 [95% CI，1.03 - 1.23]），退伍军人物质使用障碍（OR，1.11 [95% CI，1.01 - 1.22]），低收入退伍军人（OR，0.88 [95%CI，0.79 - 0.98]），以及居住在距离VHA设施较远的人群（OR，1.06 [95% CI，1.02 - 1.10]）更有可能延迟随访或无随访;风险较高的退伍军人（肺-RADS 4类与肺-RADS 1类：OR，0.35 [95% CI，0.28 - 0.43]）和在高LCS容量设施中筛选的患者（OR，0.38 [95% CI，0.21 - 0.67]）或学术机构（OR，0.86 [95% CI，0.80 - 0.92]）延迟随访或无随访的可能性较小。在敏感性分析中，不同的严格遵守的定义，预期的评价范围从14 486退伍军人（49.7%）下严格的定义，20 578退伍军人（78.8%）下自由的定义。在这项队列研究中，从综合VHA医疗保健系统和医疗保险中获得了随访护理，不到三分之二的患者在初始LCS后接受了及时推荐的随访，边缘化人群中延迟或缺乏随访的风险更高，例如黑人个体，患有精神健康障碍的个体和低收入的个体，长期以来在肺癌结局方面存在差异。今后的工作应侧重于确定促进高依从性的设施，并传播成功的战略，以促进边缘化人口在地方社区服务中的平等。
What factors are associated with adherence to recommended testing after initial lung cancer screening in the Veterans Health Administration? In this retrospective cohort study of 28 294 veterans, more than one-quarter of veterans received delayed or no follow-up testing. Veterans with higher risk findings and those in high-volume or academic centers were more likely to receive timely follow-up, while Black veterans, veterans with mental health disorders, and veterans with lower income were more likely to have delayed or absent follow-up. These findings suggest that even in an integrated health care system, inequities in adherence to lung cancer screening persisted. This cohort study examines adherence to follow-up testing recommendations after lung cancer screening among US veterans. 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. 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. 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. 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. 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. 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.
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