Dilemma solved: How to boost adherence to Fleischner Society guidelines

Data suggest radiologists’ adherence to Fleischner Society guidelines for managing pulmonary nodules incidentally detected on CT hovers in the 34 to 57 percent range. However, Beth Israel Deaconess Medical Center in Boston touts 82.8 percent adherence, likely related to departmental strategies, according to an article published in the June issue of Journal of American College of Radiology.  

Ronald L. Eisenberg, MD, JD, of Beth Israel Deaconess Medical Center, anecdotally observed a significant discrepancy between the radiology department’s adherence to Fleischner Society guidelines and typical adherence reported in clinical literature.

Eisenberg noted the management dilemma posed by incidental detection of pulmonary nodules; until 2005, standard practice consisted of frequent follow-up, instigating cost concerns and radiation exposure. However, in 2005, the Fleischner Society issued guidelines for management of small pulmonary nodules incidentally detected via CT.

A pair of recent reports documented tepid adherence to the guidelines. Eisenberg devised a study to examine adherence at Beth Israel. He mined data in the electronic messaging system to identify relevant CT exams over a three-year period.

Of the 1,412 patients who underwent chest and abdominal CT studies with abnormal findings communicated via electronic messaging, 420 had newly detected pulmonary nodules. A total of 205 were excluded due to concurrent or previous malignancies or findings highly suggestive of malignancy, inflammation or infection.    

Eisenberg reported a Fleischner Society compliance rate of 82.8 percent across the three types of chest CT exams. He offered several potential explanations for the high rate of compliance at Beth Israel.

These include a lack of policy requiring use of Fleischner guidelines at the other institutions. Although radiologists can cut and paste prespecified text relating to Fleischner guidelines in their reports, few use the option. Instead, most radiologists rely on their own language. Another report suggested it can be difficult to remember specific recommendations.

“Our department emphasizes adherence to the Fleischner guidelines because of their ability to reduce both patient radiation exposure and health care costs.” Beth Israel posts cards with the guidelines printed on them next to PACS workstations or dictating systems. In addition, it emphasizes adherence to the guidelines to residents during training.

Despite existing evidence to the contrary, compliance with Fleischner guidelines is possible, according to Eisenberg, “as long as this practice is stressed in the radiology department.”