Pack-Year Cigarette Smoking History for Determination of Lung Cancer Screening Eligibility Comparison of the Electronic Medical Record versus a Shared Decision-making Conversation

Rationale: Implementation of lung cancer screening programs is occurring across the United States. Programs vary in approaches to patient identification and shared decision-making. The eligibility of persons referred to screening programs, the outcomes of eligibility determination during shared decision-making, and the potential for the electronic medical record (EMR) to identify eligible individuals have not been well described. Objectives: Our objectives were to assess the eligibility of individuals referred for lung cancer screening and compare information extracted from the EMR to information derived from a shared decision-making conversation for the determination of eligibility for lung cancer screening. Methods: We performed a retrospective analysis of individuals referred to a centralized lung cancer screening program serving a five-hospital health services system in Seattle, Washington between October 2014 and January 2016. Demographics, referral, and outcomes data were collected. A pack-year smoking history derived from the EMR was compared with the pack-year history obtained during a shared decision-making conversation performed by a licensed nurse professional representing the lung cancer screening program. Results: A total of 423 individuals were referred to the program, of whom 59.6% (252 of 423) were eligible. Of those, 88.9% (224 of 252) elected screening. There was 96.2% (230 of 239) discordance in pack-year smoking history between the EMR and the shared decision-making conversation. The EMR underreported pack-years of smoking for 85.2% (196 of 230) of the participants, with a median difference of 29.2 pack-years. If identification of eligible individuals relied solely on the accuracy of the pack-year smoking history recorded in the EMR, 53.6% (128 of 239) would have failed to meet the 30-pack-year threshold for screening. Conclusions: Many individuals referred for lung cancer screening may be ineligible. Overreliance on the EMR for identification of individuals at risk may lead to missed opportunities for appropriate lung cancer screening.