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Frequent incorrect documentation of tobacco use for emergency department adults that qualify for lung cancer screening

Journal logoUnlabelled imageAmerican Journal of Emergency Medicine 55 (2022) 82-83

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Frequent incorrect documentation of Tobacco use for emergency department adults that qualify for Lung cancer screening

Nicholas R. Pettit ?

Department of Emergency Medicine, Indiana University, Indianapolis, IN, United States of America

1. Correspondence

Lung cancer is the leading cause of cancer death, and is the second most common cancer in the U.S., with an estimated 135,720 deaths in 2020 [1]. Meanwhile, emergency departments (ED), in particular safety-net health systems, provide care to vulnerable populations that experience disparities and barriers toward accessing recommended preventive health care such lung cancer screening (LCS) [2]. The pri- mary objective of this study is to determine the frequency by which to- bacco pack years is correctly documented in the electronic health record for adult ED smokers that would be eligible for LCS. Understand- ing the accuracy of how tobacco use is recorded in the electronic health record for ED patients will be crucial for downstream interventions that rely on this variable for interventions.

LCS saves lives, and the US Preventive services Task Force (USPSTF) recommends LCS with annual low-dose computed tomography (LDCT) for adults 50 to 80 years old, who have a 20 pack year smoking history, and currently smoke or have smoke within the past 15 years [2]. These eligibility criteria have recently been expanded from the 2013 criteria (55-80 years old, 30 pack year smoking history) to help ameliorate the known racial disparities in screening eligibility [2]. However, these changes do not address the need for improving access to equitable screening opportunities nor do they address the idea that fewer black patients have insurance that will cover LCS [3,4]. For this reason, the ED is an attractive location for targeting broad populations for preven- tive health interventions, such as LCS education or even LCS referral upon ED discharge. Correct documentation of smoking pack years in the EHR is essential for targeting LCS-eligible adults for potential LCS in- terventions. Nurses spend anywhere from 26 to 41% of their time on documentation and many mistakes are frequently observed in this doc- umentation process [5,6]. Understanding how tobacco use is recorded in the EHR is the first step to designing ED-based interventions that rely on tobacco pack years as part of the eligibility criteria.

This is a prospective cohort study from January 2019 until August 2021 in the Eskenazi Health ED, which is safety-net health system for Indianapolis Indiana. Patients were enrolled using a convenience sam- ple. This study was approved by the Indiana University’s Institutional Review Board (IU IRB), #2001677857. Adult (55-75 years old) smokers

* Corresponding author at: 720 Eskenazi Ave, 3rd Floor FOB, Department of Emergency Medicine, Indianapolis, IN 46202, United States of America.

E-mail address: [email protected] (N.R. Pettit).

(flagged by the EHR) were approached by trained research assistants, and if they were eligible for LCS they were included in this study. Since this study began in 2019 the newer LCS guidelines were not used as screening criteria [1]. Upon enrollment by a trained research personnel, the patient’s exact tobacco pack years was calculated and then compared to what was recorded in the EHR. The primary outcome of this study was the frequency at which patients had their pack years correctly documented in the EHR compared to what the research assistant calculated. We defined correctly having their pack years documented in the EHR as those patients that would be flagged LCS-eligible by the EHR if such tool was utilized in the ED.

Table 1 presents the study population included in this study, where 300 people were screened and 62 (20.6%) were eligible for LCS, thus, 20.6% (62/300) would qualify for LCS. The median age among all partic- ipants was 60 years old, with most of those patients (n = 39, 62.9%) being male. Overall, high rates of access to primary care were observed, (n = 49, 79.0%), with most patients having an insurance provider at time of ED visit (n = 59, 90.3%). Table 1 also segregates the cohort into two groups, those patients that had their pack years incorrectly re- corded in the EHR (n = 46, 74.2%), and those that had their pack years correctly recorded in the EHR (n = 16, 25.8%). No differences were ob- served for any of the covariates between the 2 cohorts.

Table 2 presents the primary outcome of the study, that is 46 (74.2%) of patients had their tobacco pack years incorrectly recorded in the EHR. Among the 46 patients with incorrect documentation, 58.7% (27/46) either had 0- or missing- pack years recorded, despite being recorded as smokers Additionally, for the remaining 19 that had their pack years incorrectly documented, the median pack years for that group was 15.0. Comparatively, the actual pack years for that entire cohort should have been 43.8, with a mean difference of 35.0 (95% CI 27.5-45.0, p < 0.001).

The ED is a novel and promising location to reduce health disparities for vulnerable populations that rely on the ED for care [2]. The EHR is a unique and functional tool for targeting populations for these focused interventions. Many successful examples have demonstrated efficacy in exploiting the EHR for targeted interventions, such as an EHR-based intervention to improve tobacco treatment in primary care [7]. minority groups, including black Americans and the uninsured receive disparate treatments for most medical conditions, have less access to routine and preventive health care, and are more likely to seek care in the ED [8]. The same populations that will likely receive increased eligibility for from the new USPSTF LCS recommendations are likely among the

https://doi.org/10.1016/j.ajem.2022.02.057

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N.R. Pettit American Journal of Emergency Medicine 55 (2022) 8283

Table 1

Study population for emergency department smokers.

Total

Incorrect pack years recorded in EHR#

Correct pack years recorded in EHR

Total

62

46 (74.2%)

16 (25.8%)

Age, meadian (IQR)

60 (7.0)

62 (8.5)

62 (3.0)

Sex (male)

39 (62.9%)

27 (58.7%)

12 (75.0%)

Race (white)?

35 (56.5%)

26 (56.5%)

9 (56.3%)

Race (black)

26 (41.9%)

19 (41.3%)

7 (43.8%)

Established primary care -yes

49 (79.0%)

37 (80.4%)

12 (75.0%

Insurance provider – yes

59 (90.3%)

42 (91.3%)

14 (87.5%)

* n=1 non-black/white.

# Electronic health record (EHR).

Table 2

Outcome data for emergency department smokers and the accuracy of recording pack years into the EHR.#

Total patients

Incorrect pack years recorded in EHR

Correct pack years recorded in EHR

62

46 (74.2%)

16 (25.8%)

Recorded smoking pack years in the EHR,? median (IQR) 25 (25)

15 0.0 (11)

42.5 (21.3)

Calculated correct smoking pack years, median (IQR) 45.0 (23.8)

43.8 (29.0)

45.0 (23.0)

Mean difference

95% CI

p value

Wilcoxon Rank Sum Test between above groups 35.0

27.5-45.0

<0.001

* 27 patients had either 0 or nothing recorded in the EHR.

# Electronic health record (EHR).

same populations that experience racial and disparities in the ED. Thus, the ED represents a potential location to target vulnerable populations who otherwise wouldn’t have access to various preventive health care, such as targeting these patients for LCS education or referral for LCS upon ED discharge.

In conclusion, our work demonstrates that among LCS-eligible adult ED patients at a safety-net ED, nearly 75% of patients have their tobacco pack years incorrectly recorded in the EHR. If an intervention was de- signed at the time of this work using EHR for targeting LCS-eligible adults, many missed opportunities would exist. With the expansion of the LCS guidelines to a lower age and lower pack years, it is likely even more patients would benefit from improving tobacco documenta- tion. Future work should look at improving tobacco use documentation in the ED-EHR [9]. Many adult smokers rely on the ED for care, and the ED thus represents an opportunity to target vulnerable populations for critical public and preventive health interventions.

Declarations of Competing Interest

None.

Author contributions statement

NP conceived the study, designed the study, and obtained IRB ap- proval. NP managed the data. NP assisted in drafting of the manuscript. NP performed statistical analysis. No funding was available for this study.

Credit authorship contribution statement

Nicholas R. Pettit: Writing – original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptual- ization.

References

  1. Force USPST, Krist AH, Davidson KW, Mangione CM, Barry MJ, Cabana M, et al. Screen- ing for lung cancer: US preventive services task force recommendation statement. JAMA. 2021;325(10):962-70. https://doi.org/10.1001/jama.2021.1117.
  2. Adler D, Abar B, Wood N, Bonham A. An intervention to increase uptake of cervical Cancer screening among emergency department patients: results of a randomized pilot study. J Emerg Med. 2019;57(6):836-43. https://doi.org/10.1016/j.jemermed. 2019.07.021.
  3. Lozier JW, Fedewa SA, Smith RA, Silvestri GA. Lung Cancer screening eligibility and screening patterns among black and white adults in the United States. JAMA Netw Open. 2021.;4(10):e2130350. https://doi.org/10.1001/jamanetworkopen.2021. 30350.
  4. Wiener RS, Rivera MP. Access to lung Cancer screening programs in the United States: perpetuating the inverse care law. Chest. 2019;155(5):883-5. https://doi.org/10. 1016/j.chest.2019.01.018.
  5. Yen PY, Kellye M, Lopetegui M, Saha A, Loversidge J, Chipps EM, et al. Nurses’ time al- location and multitasking of nursing activities: a time motion study. AMIA Annu Symp Proc. 2018;2018:1137-46. https://www.ncbi.nlm.nih.gov/pubmed/30815156.
  6. Bell SK, Delbanco T, Elmore JG, Fitzgerald PS, Fossa A, Harcourt K, et al. Frequency and types of patient-reported errors in electronic health record ambulatory care notes. JAMA Netw Open. 2020.;3(6):e205867. https://doi.org/10.1001/jamanetworkopen. 2020.5867.
  7. Linder JA, Rigotti NA, Schneider LI, Kelley JH, Brawarsky P, Haas JS. An electronic health record-based intervention to improve tobacco treatment in primary care: a cluster-randomized controlled trial. Arch Intern Med. 2009;169(8):781-7. https:// doi.org/10.1001/archinternmed.2009.53.
  8. Zhang X, Carabello M, Hill T, Bell SA, Stephenson R, Mahajan P. Trends of racial/ethnic differences in emergency department care outcomes among adults in the United States from 2005 to 2016. Front Med (Lausanne). 2020;7:300. https://doi.org/10. 3389/fmed.2020.00300.
  9. Ogawa K, Koh Y, Kaneda H, Izumi M, Matsumoto Y, Sawa K, et al. Can smoking dura- tion alone replace pack-years to predict the risk of smoking-related oncogenic muta- tions in non-small cell lung cancer? A cross-sectional study in Japan. BMJ Open. 2020.; 10(9):e035615. https://doi.org/10.1136/bmjopen-2019-035615.

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