The following article is a part of conference coverage from the 2021 American Association of Nurse Practitioners National Conference (AANP 2021), held virtually from June 15 to June 20, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading NPs. Check back for more from AANP 2021.


Screening rates for lung cancer remain low in the United States. Although primary care providers are frequently the initial point of contact for patients at high risk of lung cancer, the current system requires changes to best facilitate the coordination of services for these patients, according to research presented at the 2021 American Association of Nurse Practitioners National Conference (AANP 2021).1

In 2018, the rates of cigarette smoking in North Carolina exceeded national averages at a rate of 17.9% vs 16.4%. Medicaid enrollees in North Carolina aged 16 to 64 years had significantly higher smoking rates — 43.3% — compared with non-Medicaid residents of North Carolina and the United States as a whole, noted study authors BL Lee Peterson, DNP, RN, FNP-C, and colleagues. Smoking habits were also affected by socioeconomic status, with those in low socioeconomic groups smoking more heavily and for a longer duration compared with those in higher socioeconomic classes.2

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Role of Computed Tomography Screening

Findings published in the New England Journal of Medicine indicate that low-dose chest tomography (CT) screening in patients at high risk for lung cancer — including current smokers between 55 and 74 years of age with a 30-pack-year smoking history or a “similar” smoking history in a smoker who quit within 15 years — reduces both lung cancer and all-cause mortality by 20% and 7%, respectively.3

To review the rates of lung cancer screening in North Carolina, the researchers undertook a practice improvement project with the goal of improving lung cancer screening among eligible Medicaid recipients in a rural primary care practice in North Carolina.  Goals of this project were twofold: 1) evaluate the change in primary care provider behaviors in terms of referrals for CT screening referrals following both provider education and implementation of a lung cancer risk assessment tool; and 2) evaluate descriptive data on the total Medicaid sample cohort before and after project implementation.

The study took place at a “busy” family practice employing 4 physicians and 11 advanced practice practitioners located in a North Carolina county that was ranked 1st in smoking rates (29%), 14th in lung cancer mortality, 18th in distant stage at lung cancer diagnosis, and 6th in highest percentage of Medicaid enrollees.

Researchers gathered data for 3 months before and after a lung cancer risk assessment tool was implemented at the practice. Using patient electronic health records, demographic and outcomes data were extracted, including zip code, race and ethnicity, and gender and age.

In total, the Medicaid population included 184 patients seen during the study period; of these, 34 patients met US Preventive Services Task Force (USPSTF) lung cancer screening eligibility criteria.

Compared with the preimplementation period, more patients were referred for low-dose CT screening during the postimplementation phase (6% vs 19%); this change did not reach statistical significance. The percentage of eligible patients who were not referred for lung cancer screening was lower in the postimplementation vs preimplementation group (50% vs 61%). In both cohorts, none of the patients who were referred for screening declined to be screened.

Three patients who were referred for screening during the postimplementation phase were also seen during the preimplementation phase; however, no documentation existed to determine why these patients had not been previously referred for screening. Additionally, all patients who were referred for screening had documentation for all elements required for payor coverage — including smoking cessation and abstinence counseling.

Overall, investigators found that documentation of patient smoking history is an “area for improvement” at this particular site to increase screening referral rates. One limitation of this study is that 89% of patients in the Medicaid practice population [n=118]) had no documented smoking history, which may have negatively affected the number of patients who met screening criteria.

“The primary care provider most often represents the initial point of coordination of preventative care and is an important link between the high-risk lung cancer patient and the [low-dose CT] screening center,” the researchers concluded. “White this single-site quality improvement project did not show improvement in [low-dose CT] screening referral rates, it does provide clinically meaningful data on current…referral rates in a high-risk North Carolina Medicaid population, which is not…in the currently published health care literature.”

Visit Clinical Advisor’s meetings section for complete coverage of AANP 2021. All conference sessions are available to registered attendees through August 31, 2021.


  1. Peterson BJL, Darrow T, Palmer C, Mayer DK. Improvising lung cancer screening and referral rates of North Carolina Medicaid enrollees in a primary care practice. Poster presented at: 2021 American Association of Nurse Practitioners National Conference; June 15-June 20, 2021.. Poster 27.
  2. Garrett BE, Martell BN, Caraballo RS, King BA. Socioeconomic differences in cigarette smoking among sociodemographic groups. Prevent Chronic Dis. 2019;16:180553. doi:org/10.5888/pcd16.180553
  3. Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi:10.1056/NEJMoa1102873