National Survey of Hospitalists’ Experiences with Incidental Pulmonary Nodules
Incidental pulmonary nodules (IPNs) are common and often require follow-up. The Fleischner Society guidelines were created to support IPN management. We developed a 14-item survey to examine hospitalists’ exposure to and management of IPNs. The survey targeted attendees of the 2016 Society of Hospital Medicine (SHM) annual conference. We recruited 174 attendees. In total, 82% were identified as hospitalist physicians and 7% as advanced practice providers; 63% practiced for >5 years and 62% supervised trainees. All reported seeing ≥1 IPN case in the past six months, with 39% seeing three to five cases and 39% seeing six or more cases. Notwithstanding, 42% were unfamiliar with the Fleischner Society guidelines. When determining the IPN follow-up, 83% used radiology report recommendations, 64% consulted national or international guidelines, and 34% contacted radiologists; 34% agreed that determining the follow-up was challenging; only 15% reported availability of automated tracking systems. In conclusion, despite frequent IPN exposure, hospitalists are frequently unaware of the Fleischner Society guidelines and rely on radiologists’ recommendations.
© 2019 Society of Hospital Medicine
Pulmonary nodules are common, and their identification is increasing as a result of the use of more sensitive chest imaging modalities.1 Pulmonary nodules are defined on imaging as small (≤30 mm), well-defined lesions, completely surrounded by pulmonary parenchyma.2 Most of the pulmonary nodules detected incidentally (ie, in asymptomatic patients outside the context of chest CT screening for lung cancer) are benign.1 Lesions >30 mm are defined as masses and have higher risks of malignancy.2
Because the majority of patients will not benefit from the identification of incidental pulmonary nodules (IPNs), improving the benefits and minimizing the harms of IPN follow-up are critical. The Fleischner Society3 published their first guideline on the management of solid IPNs in 2005,4 which was supplemented in 2013 with specific guidance for the management of subsolid IPNs.5 In 2017, both guidelines were combined in a single update.6 The Fleischner Society recommendations for imaging surveillance and tissue sampling are based on nodule type (solid vs subsolid), number (single vs multiple), size, appearance, and patient risk for malignancy.
For IPNs identified in the hospital, management may be particularly challenging. For one, the provider initially ordering the chest imaging may not be the provider coordinating the patient’s discharge, leading to a lack of knowledge that the IPN even exists. The hospitalist to primary care provider (PCP) handoff may also have vulnerabilities, including the lack of inclusion of the IPN follow-up in the discharge summary and the nonreceipt of the discharge summary by the PCP. Moreover, because a patient’s acute medical problems often take precedence during a hospitalization, inpatients may not even be made aware of identified IPNs and the need for follow-up. Thus, the absence of standardized approaches to managing IPNs is a threat to patient safety, as well as a legal liability for providers and their institutions.
To better understand the current state of IPN management in our own institution, we examined the management of IPNs identified by chest computed tomographies (CTs) performed for inpatients on our general medicine services over a two-year period.7 Among the 50 inpatients identified with IPNs requiring follow-up, 78% had no follow-up imaging documented. Moreover, 40% had no mention of the IPN in their hospital summary or discharge instructions.
To inform our approach to addressing this challenge, we sought to examine the practices of hospitalist physicians nationally regarding the management of IPNs, including hospitalists’ familiarity with the Fleischner Society guidelines.
