Delayed Diagnosis and Treatment for a Patient’s Lung Cancer and Deficiencies in the Lung Cancer Screening Program at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations related to a patient’s care and the lung cancer screening (LCS) program at the VA Eastern Kansas Healthcare System (system) in Topeka and Leavenworth.

The OIG substantiated that a patient experienced a delay in the diagnosis of and treatment for lung cancer. Neither the patient aligned care team (PACT) provider nor the system pulmonologist took the necessary steps to ensure a bronchoscopy was ordered and completed. The PACT provider ordered, but failed to track, a positron emission tomography (PET) scan completed by a community provider; and failed to communicate the abnormal results to the patient and initiate clinical actions as indicated. System leaders conducted an institutional disclosure to the patient; however, the institutional disclosure documentation did not include required details.

The OIG identified concerns related to the absence of an established process for community care providers to communicate abnormal test results directly to the system’s ordering providers.

Community care staff did not make timely, sufficient efforts to retrieve the patient’s PET scan results. The OIG found a broad system failure of community care staff not making three attempts to retrieve patient records within 90 days of completed appointments, which leaders partially attributed to metrics that prioritized receiving and scheduling community care appointments.

System and program leaders failed to develop the LCS program infrastructure prior to implementation. The LCS program lacked oversight, multidisciplinary engagement, policy, and adequate primary care training and engagement.

The OIG made one recommendation to the Under Secretary for Health related to the communication of patients’ abnormal test results and one recommendation to the Veterans Integrated Service Network Director regarding the system’s LCS program. The OIG made four recommendations to the System Director related to test results, institutional disclosures, and community care records.