QUERI Citations
Zeliadt SB, Takasugi J, Todd KL, Hammond KW, Laundry R, Feemster LM, Helfrich CD, Reinke LF, Dawadi S, Greene PA, Au DH. Incomplete and Inappropriate Recommendations by Radiologist for Small and Stable Lung Nodules. Poster session presented at: American Thoracic Society Annual International Conference; 2016 May 13; San Francisco, CA.
Abstract: Rationale: Following small nodules inappropriately is potentially harmful because it leads to excessive radiation exposure from repeated tests, puts patients at risk of unnecessary invasive procedures, anxiety resulting from prolonged surveillance, and waste of clinical resources. Recent guidelines, including recommendations from Choosing Wisely, have emphasized that small and stable lung nodules should not be routinely followed.
Methods: As part of a quality improvement initiative, we reviewed radiology reports of 153 cancer-free patients identified in 2011 with pulmonary findings or lung nodules on CT imaging. Findings were grouped into three categories: 1) very small ( 4mm); 2) benign/stable; and 3) indeterminate require additional surveillance. An expert radiologist reviewed recommendations and clinical indications included in the text report classifying follow-up recommendations as appropriate, inappropriate or incomplete. A small number of cases were reviewed by an expert pulmonologist when the radiologist requested an additional opinion about the interpretation of text.
Results: Our review focusing on 139 (91%) of patients with small and stable nodules found that only 47% of very small nodules (category 1) or clearly benign or stable nodules (category 2) received an appropriate recommendation from the radiologist in the CT report. A total of 9% had an inappropriate follow-up recommendation usually for repeat of additional unnecessary imaging in 6 months when the nodule had been shown to be stable, and the remaining 43% had incomplete or vague follow-up recommendations. Among the 14 (9%) of patients with indeterminate nodules (category 3), 43% had an appropriate follow-up recommendation included in the text report, with an additional 43% receiving an incorrect recommendation with the follow-up interval not appropriately specified, and 14% had missing or incomplete recommendations.
Conclusions: The clinical indication in the CT report is a critical determinant of how pulmonary nodules are managed. Reducing unnecessary follow-up of small and stable pulmonary nodules will require improvement in completeness and appropriateness of recommendations from radiologists. Quality improvement initiatives are needed to understand and address why as few as a third of radiologists' recommendations do not include recommendations that are consistent with professional guidelines. Efforts to reduce inappropriate or unclear follow-up recommendations should be prioritized in anticipation of increasing rates of detection of small nodules associated with lung cancer screening.