Patient characteristics associated with adherence of pulmonary nodule guidelines
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BACKGROUND: Pulmonary nodules are a frequent incidental finding on CT imaging and present a diagnostic challenge to clinicians, who must balance the risks of under-evaluation and over-evaluation. Determining why patients have delayed or no follow-up for incidentally found nodules is critical to optimizing pulmonary nodule outcomes and improving early detection of potential lung malignancy. METHODS: I performed a retrospective analysis of all patients found to have new pulmonary nodules on CT imaging at Boston University Medical Center between January 1, 2011 and June December 31, 2014. The primary outcome was rate of pulmonary nodule follow-up consistent with the 2005 Fleischner Society Guidelines. I assessed how various patient demographic and clinical factors were associated with whether timely follow-up occurred in order to identify potential characteristics that may contribute to non-guideline adherent evaluation. RESULTS: Among 3916 patients found to have a pulmonary nodule during the study period, 1152 patients met study criteria. In the study population, 613 patients (53.2%) had follow-up consistent with the 2005 Fleischner Society Guidelines. In bivariate analysis, increasing nodule size, white non-Hispanic race/ethnicity, and a co-diagnosis of COPD were associated with guideline concordant follow-up. In multivariate analysis, patients with nodules measuring 7–8mm (OR 1.58, CI 1.06–2.37) and greater than 8mm (OR 1.63, CI 1.12–2.37) were more likely to have guideline concordant follow-up as were patients with a co-diagnosis of COPD (OR 2.00, CI 1.45–2.75). Hispanic patients were significantly less likely to have guideline concordant follow-up (OR 0.59, CI 0.36–0.97) compared to white non-Hispanics and uninsured patients were less likely to have guideline concordant follow-up (OR 0.56, CI 0.33–0.96) than patients with Medicare. Similar patterns were noted in analysis of nodules at highest risk of malignancy measuring 7mm or greater. CONCLUSION: Overall, the rate of guideline concordant pulmonary nodule follow-up evaluation was found to be low. Guideline concordant follow-up was significantly associated with nodule size and presence of COPD, while delayed or absent follow-up was associated with Hispanic ethnicity and lack of insurance. While these factors may highlight potential targets for quality improvement, further research is needed to better understand the complexities in delivering guideline concordant care to patients in order to improve pulmonary nodule outcomes.
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