Communication and Follow‐Up of Incidental Lung Nodules Found on Chest Ct in a Hospitalized and Ambulatory Patient Population

Background:

Incidental findings on diagnostic imaging may require follow‐up to exclude malignancy or other conditions. Previous studies have documented the prevalence of such findings, but an observational study of notification of patients and primary care providers (PCPs) about incidental radiologic findings has not been described. We evaluated the follow‐up of incidental lung nodules on computed tomography (CT) scans in a general medicine hospitalist and ambulatory patient population.

Methods:

The reports of all chest CT scans performed at our University Hospital 1/1/2011‐12/31/2012 were retrospectively screened for “Fleischner,” as the Fleischner Society guidelines are used to recommend follow‐up for incidental lung nodules. In addition to an incidental lung nodule, inclusion criteria were age 35 years or older and either a PCP in the Division of General Internal Medicine (DGIM) or admission to a DGIM Hospitalist attending. A 38‐item data abstraction tool was designed by investigators to describe the patient population, define appropriate follow up, and record the presence or absence of communication to the patient and PCP and follow‐up imaging as documented in the electronic medical record (EMR). All charts were reviewed by a single investigator and 10% were double reviewed by a second investigator to determine inter‐rater reliability.

Results:

At our hospital, 860 patients were identified with an incidental lung nodule on CT scan. Of 371 patient charts reviewed to date, 63 met inclusion criteria. In 44 of the 63 patients (70%), follow‐up imaging for the incidental lung nodule was recommended. 25 (57%) follow‐up recommended (FR) nodules were found in the hospital setting and 19 (43%) in a primary care setting. Of patients with a FR nodule, 32 (73%) have PCPs in our health care system, 5 (11%) had out of system PCPs and 7 (16%) had no PCP listed. 50% of all patients with a FR nodule were ordered follow‐up imaging as an outpatient, 43% had imaging performed and 23% in the appropriate timeframe. In an analysis of the 25 FR nodules discovered in the hospital, 14 (56%) FR nodules are documented in the patients’ discharge instructions and 12 (48%) FR nodules are mentioned in the patients’ discharge summary. 7 (28%) of all the patients with FR nodules found in the hospital had follow up imaging in our EMR. Among patients with PCPs in our health system for whom all follow‐up records are available for review, 5 of 13 FR nodules (38%) found in the hospital received any follow up imaging.

Conclusions:

The majority of incidental lung nodules identified during routine primary and hospital based care require follow‐up imaging; however only a minority received imaging in the appropriate timeframe in our study. Poor documentation and lack of provider and patient communication around incidental radiologic findings during transitions of care is prevalent and represent targets for quality improvement to reduce preventable harm in hospitalized and ambulatory patients.