We explore key considerations for the success of the lung cancer screening programme in Croatia, discussing the pivotal role that integrated technology and reimbursement for primary care providers have played.
Securing commitment to lung cancer screening in Croatia
Croatia introduced a national lung cancer screening programme in October 2020, becoming the first country in the European Union (EU) to do so. This followed a recommendation from the working group of the Croatian Thoracic Society and the Section for Thoracic Radiology of the Croatian Society of Radiologists. The recommendation was based on the wealth of international evidence for lung cancer screening without the need for national pilots.
The screening programme is targeted at people aged 50 to 75, with a smoking history of 30 pack-years, who currently smoke or have stopped smoking within the past 15 years.
The programme is financed by the Croatian Health Insurance Fund. By 2025, it aims to achieve a screening coverage of 50% of the target population and reduce mortality by 20%.
Recruiting eligible participants for the screening programme
For lung screening in Croatia, individuals are recruited directly by primary care physicians. This differs from other types of cancer screening, for which invitations are sent centrally from the Ministry of Health. Primary care physicians are responsible for identifying people who are eligible for lung cancer screening and directly making a screening appointment for them. This approach was selected partly because everyone in Croatia has a dedicated primary care physician and a high proportion of people visit them at least once a year (approximately 90%).
Physicians are supported in this recruitment activity through training and technology. Medical health records are available to primary care physicians to inform them of relevant information such as people’s smoking status and comorbidities (e.g. chronic obstructive pulmonary disease). There is also a national digital platform which is used to schedule appointments at one of 16 certified screening centres.
Alongside this, training has been provided to improve awareness of the programme, its eligibility criteria and the process for referral. This has led to improved knowledge of screening among primary care physicians which has corresponded to an increase in participation in the screening programme.
Primary care physicians are reimbursed to recognise the additional work involved in recruiting and referring eligible people and to mitigate concerns about the time commitment required.
Delivering accessible scans and follow-up
Croatia’s screening centres are strategically located so that everyone can access one within 50 kilometres. This aims to limit excessive travel distance, time and expense for screening participants. Screening centres must satisfy minimal technical criteria and, to ensure quality of service provision, operating radiologists are required to have conducted a minimum number of computed tomography (CT) scans per year and to have attended two training courses.
Individuals without suspicious findings during the initial scan are eligible for a follow-up scan after one year and then a scan every two years until the age of 75. Individuals with suspicious findings are referred to one of six nodule clinics around the country, staffed by a multidisciplinary team that provides follow-up diagnostics including further imaging and biopsies.
The impact of the screening programme so far
Since the programme’s inception, 14,000 scans have been completed and over 11,000 participants enrolled. This has led to an observed stage shift to the earlier detection of lung cancer, which is associated with increased treatment options and improved survival.
To date, no formal assessment of the success of the programme has been made, although evaluation has been specifically built into its design.
To learn more about the lung cancer screening programme in Croatia watch our video with Network member Dr Ante Marušić. The Lung Cancer Policy Network is publishing brief case studies of countries that have implemented LDCT screening; you can read other examples here.
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