Outcomes of Incidental Lung Nodules With Structured Recommendations and Electronic Tracking

Barun Bagga; Kush Fansiwala; Shailin Thomas; Ryan Chung; William H Moore; James S Babb; Leora I Horwitz; Saul Blecker; Stella K Kang

doi:10.1016/j.jacr.2021.09.046

Outcomes of Incidental Lung Nodules With Structured Recommendations and Electronic Tracking

J Am Coll Radiol. 2022 Mar;19(3):407-414. doi: 10.1016/j.jacr.2021.09.046. Epub 2021 Dec 8.

Authors

Barun Bagga¹, Kush Fansiwala², Shailin Thomas², Ryan Chung³, William H Moore⁴, James S Babb⁵, Leora I Horwitz⁶, Saul Blecker⁷, Stella K Kang⁸

Affiliations

¹ Cardiothoracic Imaging Fellow, Department of Radiology, NYU Grossman School of Medicine, New York.
² NYU Grossman School of Medicine, New York, New York.
³ Department of Population Health, NYU Grossman School of Medicine, New York, New York.
⁴ Professor, Radiology; Section Chief, Thoracic Imaging; and Associate Chair, Clinical informatics, Department of Radiology, NYU Grossman School of Medicine, New York, New York.
⁵ Associate Professor, Department of Radiology, NYU Grossman School of Medicine, New York, New York.
⁶ Professor and Division Director, Departments of Population Health and Medicine; and Director, Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York.
⁷ Assistant Professor, Departments of Population Health and Medicine; and Associate Director, Research, Division of Hospital Medicine, NYU Grossman School of Medicine, New York, New York.
⁸ Associate Professor, Department of Radiology; and Director, Comparative Effectiveness and Outcomes Research, NYU Grossman School of Medicine, New York, New York. Electronic address: stella.kang@nyulangone.org.

PMID: 34896068
DOI: 10.1016/j.jacr.2021.09.046

Abstract

Objective: To evaluate the impact of structured recommendations on follow-up completion for incidental lung nodules (ILNs).

Methods: Patients with ILNs before and after implementation of structured Fleischner recommendations and electronic tracking were sampled randomly. The cohorts were compared for imaging follow-up. Multivariable logistic regression was used to assess appropriate follow-up and loss to follow-up, with independent variables including use of structured recommendations or tracking, age, sex, race, ethnicity, setting of the index test (inpatient, outpatient, emergency department), smoking history, and nodule features.

Results: In all, 1,301 patients met final inclusion criteria, including 255 patients before and 1,046 patients after structured recommendations or tracking. Baseline differences were found in the pre- and postintervention groups, with smaller ILNs and younger age after implementing structured recommendations. Comparing pre- versus postintervention outcomes, 40.0% (100 of 250) versus 29.5% (309 of 1,046) of patients had no follow-up despite Fleischner indications for imaging (P = .002), and among the remaining patients, 56.6% (82 of 145) versus 75.0% (553 of 737) followed up on time (P < .001). Delayed follow-up was more frequent before intervention. Differences postintervention were mostly accounted for by nodules ≤8 mm in the outpatient setting (P < .001). In multivariable analysis, younger age, White race, outpatient setting, and larger nodule size showed significant association with appropriate follow-up completion (P < .015), but structured recommendations did not. Similar results applied for loss to follow-up.

Discussion: Consistent use of structured reporting is likely key to mitigate selection bias when benchmarking rates of appropriate follow-up of ILN. Emergency department patients and inpatients are at high risk of missed or delayed follow-up despite structured recommendations.

Keywords: Fleischner Society; incidental finding; lung nodule; quality improvement; structured reporting.

MeSH terms

Electronics
Humans
Incidental Findings
Lung
Lung Neoplasms* / diagnostic imaging
Solitary Pulmonary Nodule* / diagnostic imaging

Grants and funding

P30 HS024376/HS/AHRQ HHS/United States