Scrodin, M. Dulohery

Abstract Background Despite the reported benefits, lung cancer screening (LCS) uptake remains alarmingly low in comparison to other cancer screening programs. Objective To develop and evaluate an automated, electronic health record (EHR)-embedded LCS outreach program designed to increase screening uptake while minimizing workload for referring providers and schedulers. Methods We developed an automated outreach and referral program at two Mayo Clinic campuses (Rochester [RST] and northwest Wisconsin [NWW]) coupled with a streamlined virtual care delivery process. Eligible patients were identified based on the information in the EHR regarding US Preventive Services Task Force guidelines for screening and were contacted through either a patient portal message, letter, or both. Outreach included LCS educational materials and self-scheduling instructions for a telephone or video shared decision-making (SDM) visit. During the visit, a licensed care team member discussed the risks and benefits of a low dose computed tomography (LDCT) scan with patients who could choose to enroll in the Lung Cancer Screening Program or decline. Results During the study period, 8,845 eligible patients (RST: 2201, NWW: 6644) were contacted using automated portal messages, letters, or both. Among the RST cohort, 2,156 portal messages and 1,060 letters were distributed in comparison to 7,642 portal messages, 6,441 letters, and 618 text messages in the NWWI cohort. The study showed increase in shared decision-making visits completion and screenings for eligible patients across both groups. Portal engagement was higher among the RST group 75.4% than 55.8% in the NWWI group, as was digital brochure access (14.1% vs 6.5%). Scheduling for share-decision-making visits was noted to be higher among the RST group (22% vs 13.6%), though visit completion rates were similar across sites (12.6 vs 13.6%). A lower opt-out rate was noted among the RST group (12.6% vs. 14.3%). Collectively, both campuses demonstrated meaningful patient engagement. Conclusion The automated outreach program effectively increased lung cancer screening engagement and uptake for eligible patients without adding significant administrative burden on primary care providers and clinical staff. Observed differences in engagement between sites, as well as relatively low completion rates highlight the need for further investigation into contextual and operational factors influencing program performance. This abstract is funded by: none

Abstract Introduction Mediastinal masses encompass broad differentials of reactive, inflammatory, infectious or neoplastic etiology. In the background of extra thoracic malignancy, it raises a high suspicion for primary cancer or metastatic lymphadenopathy. However, a benign anatomical variant can mimic these findings and lead to unnecessary diagnostic procedures and patient anxiety. Recognizing mimickers becomes crucial in avoiding misdiagnosis and overtreatment. Case A 50-year-old woman with no significant past medical history presented with a two-day history of headache, associated with cough, orthopnea and lower extremity edema. Vital signs were significant for elevated blood pressure at 199/107 mm Hg. Laboratory findings noted a markedly elevated B-type natriuretic peptide (19,000 pg/mL), increased serum creatinine (1.4 mg/dL from baseline 0.7 mg/dL) and proteinuria. Chest X-ray revealed pulmonary vascular congestion. Autoimmune serologies were positive for antinuclear antibody (titer 1:2560), ribonucleoprotein antibody, and RNA polymerase III antibody. Renal biopsy confirmed scleroderma renal crisis. She was treated for hypertensive emergency secondary to scleroderma renal crisis. Further evaluation for elevated total protein revealed monoclonal gammopathy on electrophoresis and 30% plasma cells on bone marrow biopsy, consistent with smoldering multiple myeloma. A chest computed tomography scan incidentally identified a 4 × 3 cm lobular right paratracheal mass. Tissue biopsy was requested to exclude plasmacytoma. Bronchoscopy with endobronchial ultrasound revealed a large hypoechoic paratracheal lesion. Biopsy was aborted due to its cystic appearance and risk of airway flooding. Subsequent magnetic resonance imaging was obtained for tissue characterization which delineated the mass as a thin walled, fluid filled structure communicating with the superior aortic recess, consistent with a high riding superior pericardial recess which is a benign anatomical variant. She was discharged with plans for outpatient multidisciplinary follow up, including pulmonary evaluation for interstitial lung disease surveillance. Discussion High riding pericardial recess is a benign anatomical variant which can closely mimic pathologic masses or lymphadenopathy on cross sectional imaging. Key is identification of probable communication with the superior aortic recess associated with fluid attenuation. Knowledge of anatomy, comprehensive multimodal imaging review, and multidisciplinary discussion are key to prevent unnecessary investigation of mediastinal abnormalities. This abstract is funded by: None

Abstract Introduction: The variety of pulmonary function tests (PFTs) offered in the pulmonary function lab (PFL) can confuse providers unfamiliar with the clinical role of the individual components of the PFT, potentially leading to repeat tests, diagnostic delays, patient burden, and reduced lab efficiency. We hypothesized that a symptom- and diagnosis-based ordering set will reduce the need for repeat testing visits. Methods: Baseline data (June 2022-June 2023) were first collected to establish PFL performance benchmarks and identify common reasons for incomplete or repeat PFL visits. We then implemented an electronic order set reflecting the clinical need of the PFT, based on symptoms, diagnoses, suspected diagnoses, or other common clinical indication in addition to a physician-supervised, results-driven protocol to allow de-escalation of testing when appropriate The pre-implementation data was compared to the post-implementation data (July 2023-June 2024), evaluating for its impact on PFL access, utilization of the specific PFT components (e.g. methacholine challenge test, MCT), and on diagnoses. Results: During the study period 52,292 PFTs were performed during the pre-implementation phase compared to 58,310 tests in the post-implementation phase. Following intervention, the need for a second PFL visit for the same clinical indication decreased from 26% to 13% (p<0.0001). The same day PFL capacity increased by 3-4 patients per day. 80% of primary care providers reported the new order design was more intuitive and easier to use. Among the specific components of the PFT, there was a significant increase in the number MCTs being performed, from 2.5% to 4%, (p<0.0001), with a change rate ranging between 26 – 81% / month. In a subset analysis of 57 consecutive patients having MCTs, the primary indications were evaluation for cough or wheezing (57.9%), initial asthma evaluation (22.8%), and specifically requested by the ordering provider (19.3%). MCT was not performed in 23% due to a low baseline lung function, difficulty with repeatable efforts, recent bronchodilator administration, or due to complicating comorbidities. Of the 39 tests completed, 89% were deemed appropriate, with 32% having positive results and 42% ultimately diagnosed with asthma. Conclusions: A symptom and/or diagnosis guided ordering set for pulmonary function testing appears to improve the efficiency of the PFL, while improving provider experience, PFL access, as well as on patient burden and diagnoses. Further research is needed to determine potential benefits for provider decision-making and patient outcomes.

Abstract Introduction: Chronic obstructive pulmonary disease (COPD) is a top 5 cause of death and bears significant morbidity and mortality. The role of multimorbidity in patients with COPD has been shown to affect quality of life, increase risk of disease exacerbation, and mortality. COPD-targeted treatments have shown limited effects on mortality, but this patient population may benefit from practitioners more aggressively managing other comorbid conditions. Understanding which diseases have the largest impact on mortality in COPD patients may help providers understand which comorbidities to manage aggressively. Methods: We used the National Vital Statistics System (NVSS; 2019 data release), which collects all death certificate data for US citizens along with basic demographic information. We only included those who died with COPD as a diagnosis on their death certificate, defined as those who had international classification of disease, version 10 (ICD-10) codes J40-J44. We then dichotomized the causes of death by COPD vs non-COPD causes, based on the underlying cause of death (UCOD) on the death certificate. UCOD is defined by the NVSS as “the disease or injury which initiated the train of events leading directly to death.” Demographic information was collected, race was self-reported, and level of education was dichotomized as less than HS diploma vs higher. We used chi-square or t-test to determine statistical significance (defined as p <0.05) between groups for demographic information. Results: 308,856 US adults had an ICD-10 code associated with COPD written on their death certificate, of these 156,499 (50.6%) had a UCOD other than COPD. Overall, mean age 77.1 years (SD 2.6 years), 49% were female. The 10 most common diagnoses of those who died of non-COPD causes are presented in Figure 1, with the three most common causes being lung cancer (23689, 15.1%), atherosclerotic heart disease (22,848, 14.6%), and acute myocardial infarction (6422, 4.1%). Six of the top 10 are cardiovascular diseases. Conclusion: Patients with COPD are at high risk of mortality from comorbid conditions, with around 50% dying from non-COPD etiologies according to death certificate data. Most of these etiologies have evidence-based and mortality-reducing interventions such as lung cancer screening and management of cardiovascular risk factors including cholesterol-lowering medications and antihypertensives. While we don't have more granular data in terms of medications and therapies, these findings suggest that guideline-oriented approaches, both in terms of lung cancer screening and cardiovascular-risk reduction, may have a strong impact on mortality reduction in this patient population.