Outcomes of Incidental Lung Nodules With Structured Recommendations and Electronic Tracking

To evaluate the impact of structured recommendations on follow-up completion for incidental lung nodules (ILNs).

Patients with ILNs before and after implementation of structured Fleischner recommendations and electronic tracking were sampled randomly. The cohorts were compared for imaging follow-up. Multivariable logistic regression was used to assess appropriate follow-up and loss to follow-up, with independent variables including use of structured recommendations or tracking, age, sex, race, ethnicity, setting of the index test (inpatient, outpatient, emergency department), smoking history, and nodule features.

In all, 1,301 patients met final inclusion criteria, including 255 patients before and 1,046 patients after structured recommendations or tracking. Baseline differences were found in the pre- and postintervention groups, with smaller ILNs and younger age after implementing structured recommendations. Comparing pre- versus postintervention outcomes, 40.0% (100 of 250) versus 29.5% (309 of 1,046) of patients had no follow-up despite Fleischner indications for imaging (P = .002), and among the remaining patients, 56.6% (82 of 145) versus 75.0% (553 of 737) followed up on time (P < .001). Delayed follow-up was more frequent before intervention. Differences postintervention were mostly accounted for by nodules ≤8 mm in the outpatient setting (P < .001). In multivariable analysis, younger age, White race, outpatient setting, and larger nodule size showed significant association with appropriate follow-up completion (P < .015), but structured recommendations did not. Similar results applied for loss to follow-up.

Consistent use of structured reporting is likely key to mitigate selection bias when benchmarking rates of appropriate follow-up of ILN. Emergency department patients and inpatients are at high risk of missed or delayed follow-up despite structured recommendations.