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

Document Type


Publication Date


Publication Title

Ann Am Thorac Soc


Aged; Cigarette Smoking; Communication; Decision Making; Early Detection of Cancer; Electronic Health Records; Female; Humans; Lung Neoplasms; Male; Middle Aged; Referral and Consultation; Retrospective Studies; Risk Assessment; Tomography, X-Ray Computed; Washington


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.

Clinical Institute





Pulmonary Medicine