Lung Cancer Screening Centralization Is Associated With Improved Screening Uptake: The Veterans Healthcare...

Lung cancer is the leading cause of cancer mortality, yet lung cancer screening (LCS) remains underused. Centralizing LCS into dedicated teams with tracking systems (vs decentralized, individual provider-led screening) may improve LCS uptake, but effectiveness across diverse settings and populations is uncertain. Centralization also varies: hybrid programs share responsibilities with primary care clinicians, whereas fully centralized programs manage nearly all screening and patient navigation. Whether one model is more effective in enrolling patients remains unknown.

Is level of LCS program centralization associated with increased LCS uptake?

We performed a retrospective, longitudinal, nationwide cohort study using a difference-in-differences Poisson model using Veterans Health Administration facilities. We included veterans 55 to 80 years of age who entered screening from October 1, 2015, through September 30, 2021. The primary exposure was facility LCS program type (decentralized vs hybrid vs fully centralized). The main outcome was the incident rate ratio (IRR) of facility-level quarterly LCS uptake, normalized to their estimated LCS-eligible population.

We identified 151,194 unique veterans who underwent screening for our analysis. Overall, LCS uptake was lower for Hispanic veterans (IRR, 0.92; 95% CI, 0.90-0.93), female veterans (IRR, 0.80; 95% CI, 0.74-0.86), those 65 years of age and older (IRR, 0.81; 95% CI, 0.78-0.84), and veterans living in rural areas (IRR, 0.96; 95% CI, 0.95-0.97). Compared with decentralized programs, increasing centralization was associated with increasing LCS uptake (hybrid programs: IRR, 1.47 [95% CI, 1.25-1.72]; fully centralized programs: IRR, 1.75 [95% CI, 1.49-2.07). Hybrid programs were associated with particularly improved LCS uptake for veterans living in rural areas and more modestly for veterans from more disadvantaged regions, whereas fully centralized programs were associated with improved LCS uptake for veterans from more disadvantaged regions and veterans with higher out-of-pocket costs, although they recruited fewer veterans living in rural areas.

Both hybrid and fully centralized LCS programs were associated with improved LCS uptake, with subgroup differences suggesting model-specific advantages. However, persistent disparities highlight the need for tailored approaches to expand screening.