Watch a video about Sanford Health's lung nodule and lung screening clinics.
When radiologists at Sanford Medical Center in Fargo, N.D., heard about their hospital’s plan to offer low-dose CT (LDCT) lung cancer screening for high-risk patients in 2012, they were a bit apprehensive. The radiologists knew that lung cancer screening would require a great deal of coordination and were concerned about the time and complexity associated with monitoring patients who enrolled in the program.
“We recognized the immense potential of screening to identify lung cancer in the early stages, when it’s most treatable. But without the right follow-up procedures in place to make sure no one fell through the cracks, we thought we’d actually be doing our patients a disservice,” says Martha S. Kearns, MD, radiologist at Sanford Medical Center Fargo.
To ensure lung cancer screening patients would receive the necessary longitudinal care, the radiologists partnered with a multidisciplinary team of primary care and internal medicine physicians, nurse navigators, pulmonologists, radiation oncologists, and oncologists to establish a dedicated lung nodule clinic to track and monitor lung cancer screening patients.
Now, with a dedicated nurse navigator, the team manages patient exams, results communication, and follow-up, with radiologists providing clear and consistent recommendations based on custom guidelines that the radiologists founded in part on the ACR LUNG-RADS® reporting system. (Read more about how recommendations were developed for the team’s lung nodule clinic.) With this approach, Sanford’s lung cancer screening program has grown significantly over the years.
Since the program began in 2013 — with a hiatus in 2015 for proposed Medicare changes — over 300 different providers throughout the region have referred more than 3,900 patients for lung cancer screening. Among these patients, the radiologists have identified 44 cases of cancer, 24 of which were detected in stages 1 and 2, when the disease is still treatable.
“Working closely with family physicians and other key specialists, we’ve been able to detect lung cancer early, before symptoms even appear,” Kearns explains. “Lung cancer screening is part of our role as radiologists now, and it saves lives.”
While the self-pay model brought in a moderate but steady stream of over 200 patients in 2014, 2015 was a different story. In February of that year, CMS announced a national coverage determination for Medicare beneficiaries who meet certain eligibility criteria.3 The decision also outlined specific dose parameters, standardized reporting requirements, and other conditions for reading radiologists and participating imaging facilities. Sanford’s screening program — like other lung cancer screening programs nationwide — was suspended until it met the new requirements and CMS finalized its reimbursement codes.
From there, Sanford began implementing new processes to meet the CMS requirements for lung cancer screening, including the institution of dose reduction techniques as part of the ACR Lung Cancer Screening Registry (LCSR) and patient flow improvements within the lung nodule clinic. The on-staff radiologist would interpret the CT, share the standardized report with both the PCP — who would deliver the results to the patient — and Lacher, who, as the nurse navigator, would monitor the patient to ensure care continuation for subsequent scans.
According to Glatt, this coordinated care delivery has been vital to the screening program’s success. “Centralizing the complex, multidisciplinary process of CT screening and subsequent lung nodule management into a clinic has enabled Sanford to provide true accountability and the highest level of patient care for thousands of patients.”
The referrer education outreach efforts along with integration of LCS eligibility within the EMR spurred a significant increase in the program’s patient volume. After Medicare reimbursement for lung cancer screening was approved in late 2015, the year brought 466
patients into the program, followed by 681 patients in 2016.
As the program gained momentum, Lacher and Kearns began helping rural Sanford sites in the region adjust screening processes to meet Medicare’s requirements for a covered LDCT program and participation in the ACR LCSR. “I’ve met with various leaders of rural clinics to discuss what we’ve implemented here at Sanford and to help guide them in offering screening and follow-up access for high-risk patients in rural areas,” Kearns says.
Sanford Medical Center’s lung cancer screening volumes have continued to increase with its expanding presence in the region and within referrers’ offices, with 1,211 high-risk patients undergoing screening in 2018. Over the duration of the program, numerous lung cancers — 24 of them early stage — as well as additional cancers, were identified in 44 patients, increasing their chances of survival via various treatments.
For 2019, the Sanford lung nodule clinic has set a new goal: a 20 percent increase in scans to induce earlier nodule detection and successful treatment for at-risk patients. Lacher believes that into the next decade the lung cancer screening program could grow through the use of videoconferencing and/or even a mobile screening unit to service additional areas.
Kearns says that the program’s success can be attributed in part to radiology’s consistency in process, open-mindedness about applications, and a willingness to be hands-on in a way that demonstrates the specialty’s value. “Lung cancer isn’t going away,” she says. “As radiologists, it is our job to find it early, so we can reduce mortality, and lung cancer screening is the best way for us to do that.”
Jump-start a conversation about lung cancer screening.
Lung Screening Solutions by American College of Radiology is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Based on a work at www.acr.org/imaging3 . Permissions beyond the scope of this license may be available at www.acr.org/Legal .
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Kerri Reeves is a freelance writer