Tanner J Caverly1, Xuefei Zhang2, Rodney A Hayward3, Ji Zhu2, Akbar K Waljee4. 1. VA Ann Arbor Center for Clinical Management Research and University of Michigan Medical School, University of Michigan, Ann Arbor, MI; Institute for Health Policy Innovation, University of Michigan, Ann Arbor, MI. Electronic address: tcaverly@med.umich.edu. 2. Department of Statistics, University of Michigan, Ann Arbor, MI. 3. VA Ann Arbor Center for Clinical Management Research and University of Michigan Medical School, University of Michigan, Ann Arbor, MI; Institute for Health Policy Innovation, University of Michigan, Ann Arbor, MI. 4. VA Ann Arbor Center for Clinical Management Research and University of Michigan Medical School, University of Michigan, Ann Arbor, MI; Institute for Health Policy Innovation, University of Michigan, Ann Arbor, MI; Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI.
Abstract
BACKGROUND: Self-reported tobacco pack-year history plays a large role in decisions about low-dose CT screening for lung cancer, yet is challenging to measure accurately. RESEARCH QUESTION: To what extent does random measurement error in pack-year information impact screening decisions and screening effectiveness? STUDY DESIGN AND METHODS: Retrospective cohort study of 10,449 patients with pack-year history documented at least twice between October 2013 and July 2017 across 8 academic Veterans Affairs sites. Outcome measures included (1) observed reliability of pack-year information based on all repeat measures for the study population and (2) each person's statistically "true" pack-year information based on best linear unbiased predictor from a multilevel linear random effects model. To examine how unreliability leads to misclassification of screening eligibility and inaccuracy in estimating lung cancer risk, we simulated pack-year observations for each person, first comparing simulated pack-year and lung cancer risk values with true values, then comparing outcomes when basing screening decisions on unreliable pack-year information vs true information. RESULTS: Reliability of assessing pack-year information in routine practice varied across sites. Thus, we examined the clinical impact of two different levels of reliability, based on the range of intraclass correlation coefficients observed. Using a ≥ 30-pack-year threshold led to a high rate of eligibility misclassifications (48.1% misclassified with higher reliability pack-year information and 60.7% misclassified with lower reliability information). However, using a lung cancer risk threshold leads to fewer misclassifications (47.3%-49.7% misclassified when using lower reliability pack-year information) and maintains screening effectiveness better when using unreliable pack-year information. INTERPRETATION: Random error in real-world pack-year assessments leads to a substantial rate of misclassifying who should be offered CT screening if a ≥ 30-pack-year criterion is used. However, using a lung cancer risk threshold mitigates the impact of unreliable pack-year information. Decision-makers concerned about the impact of unreliable pack-year information should consider using risk-based approaches to CT screening. Published by Elsevier Inc.
BACKGROUND: Self-reported tobacco pack-year history plays a large role in decisions about low-dose CT screening for lung cancer, yet is challenging to measure accurately. RESEARCH QUESTION: To what extent does random measurement error in pack-year information impact screening decisions and screening effectiveness? STUDY DESIGN AND METHODS: Retrospective cohort study of 10,449 patients with pack-year history documented at least twice between October 2013 and July 2017 across 8 academic Veterans Affairs sites. Outcome measures included (1) observed reliability of pack-year information based on all repeat measures for the study population and (2) each person's statistically "true" pack-year information based on best linear unbiased predictor from a multilevel linear random effects model. To examine how unreliability leads to misclassification of screening eligibility and inaccuracy in estimating lung cancer risk, we simulated pack-year observations for each person, first comparing simulated pack-year and lung cancer risk values with true values, then comparing outcomes when basing screening decisions on unreliable pack-year information vs true information. RESULTS: Reliability of assessing pack-year information in routine practice varied across sites. Thus, we examined the clinical impact of two different levels of reliability, based on the range of intraclass correlation coefficients observed. Using a ≥ 30-pack-year threshold led to a high rate of eligibility misclassifications (48.1% misclassified with higher reliability pack-year information and 60.7% misclassified with lower reliability information). However, using a lung cancer risk threshold leads to fewer misclassifications (47.3%-49.7% misclassified when using lower reliability pack-year information) and maintains screening effectiveness better when using unreliable pack-year information. INTERPRETATION: Random error in real-world pack-year assessments leads to a substantial rate of misclassifying who should be offered CT screening if a ≥ 30-pack-year criterion is used. However, using a lung cancer risk threshold mitigates the impact of unreliable pack-year information. Decision-makers concerned about the impact of unreliable pack-year information should consider using risk-based approaches to CT screening. Published by Elsevier Inc.
Authors: Polina V Kukhareva; Tanner J Caverly; Haojia Li; Hormuzd A Katki; Li C Cheung; Thomas J Reese; Guilherme Del Fiol; Rachel Hess; David W Wetter; Yue Zhang; Teresa Y Taft; Michael C Flynn; Kensaku Kawamoto Journal: J Am Med Inform Assoc Date: 2022-04-13 Impact factor: 7.942