Impact of A Standardized Recommendation and Electronic Prompts on Follow-Up of Indeterminate Pulmonary Nodules Found on Computed Tomography

Abstract

Background: Lung cancer is the leading cause of cancer death in both men and women worldwide. Given that pulmonary nodules are a common finding on chest CT, a judicious plan for follow-up is necessary. A set of generally accepted, evidence-based guidelines have been published but a large proportion of these findings are not followed-up in a manner congruent with the guidelines. This results in both overimaging and failure of timely follow-up of potentially curable malignant lesions. Purpose: The purpose of this study was to assess the impact of a standardized template of follow-up recommendations in radiology interpretation reports and the initiation of an electronic messaging system to the clinician requesting the imaging study on the rates of appropriate radiographic follow-up of indeterminate pulmonary nodules identified on computed tomography. Description: This retrospective study examined rates of appropriate follow-up, as defined by the Fleischner Society guidelines, of incidental pulmonary nodules over two seven7-month periods both before (17 patients; mean age 62.7 years) and after (72 patients, mean age 61.6 years) the commencement of the quality improvement initiatives. Further analysis by risk, patient and nodule characteristics, notification type and location of imaging request were performed. Time-appropriate follow-up increased from 35.3% (6/17) to 56.9% (49/72) [P = 0.18]. The largest change was noted in high-risk patients with an improvement from 11.1% (1/9) appropriate follow-up to 51.4% (18/35) [P = 0.06] following the interventions. The biggest improvement in on-time follow-up imaging was a reduction in premature imaging, which decreased from 17.6% (3/17) to 6.9% (5/ 72) [P = 0.18]. Regarding patient and nodule characteris tics, the most prominent improvements in appropriate scanning interval was noted in patients aged 35-49 (0% to 50.0%; P = 0.11) and in those with nodules size >4-6mm (0% to 50.0%; P = 0.12). Conclusions: The appropriateness of follow-up imaging improved following the implementation of the quality improvement initiatives although this did not reach statistical significance. The largest improvement appeared to be for high-risk patients