Inconsistencies evident in pulmonary nodule evaluation

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Pulmonary nodule evaluation is often inconsistent with guidelines, calling for quality improvement systems before lung cancer screening is widely implemented, according to a study published online April 9 by JAMA Internal Medicine.

Guidelines exist for the evaluation of pulmonary nodules, yet little is known about how they are managed. “The intensity of evaluation has important implications for patient health, costs, and effectiveness of lung cancer screening programs,” wrote lead author Renda Soylemez Wiener, MD, MPH, of the Boston University School of Medicine, and colleagues.

To better understand how management guidelines are typically followed in care settings, the researchers addressed three questions in a sample of 300 veterans who were evaluated in 15 Veterans Affairs facilities. The questions were as follows: What resources are used to evaluate potentially malignant pulmonary nodules? Is evaluation consistent with guideline recommendations? What harms are associated with nodule evaluation?

The retrospective cohort study reviewed the medical records of those who had indeterminate pulmonary nodules. Of the 300 veterans, 27 were ultimately diagnosed with lung cancer. One of 57 had a nodule of four millimeters or less, four of 134 with a nodule of five to eight millimeters and 22 of 109 with a nodule larger than eight millimeters.

Forty-six patients underwent invasive procedures, of which 19 did not have cancer and eight had complications. Fifteen of the 300 had no purposeful evaluation and no apparent reason for deferral. Of 197 patients with a nodule detected after the release of the Fleischner Society guidelines, 44.7 percent received care that was inconsistent with the guidelines.

Mutlivariable analyses revealed that the strongest predictor of guideline-inconsistent care was inappropriate radiologist recommendations, with an overevaluation relative risk of 4.6 and an underevaluation risk of 4.3. Additional systems factors associated with underevaluation included receiving care at more than one facility and nodule detection during an inpatient or preoperative visit.

“This study raises questions about the expected cost-effectiveness and risk to benefit tradeoffs of lung cancer screening in the usual care setting,” wrote Wiener and colleagues. “Systems to improve efficiency and safety of nodule evaluation are needed, especially before wide-scale adoption of lung cancer screening.”

The authors suggested solutions such as inclusion of the Fleischner Society algorithm in radiology reports that describe pulmonary nodules and improved systems to communicate findings of a new nodule and current stage of evaluation between care teams.