Incidental pulmonary nodules reported on CT abdominal imaging: Frequency and factors affecting inclusion in the hospital discharge summary
Incidental imaging findings require an assessment of risk and clinical relevance, as well as consideration of further evaluation. Incidental findings are common on imaging obtained in the hospital, with pulmonary nodules being among the most frequent findings that may require additional evaluation. We conducted a retrospective study to determine the factors associated with documentation of incidental findings in the hospital discharge summary, using pulmonary nodules reported on abdominal computed tomography (CT) as an example of incidental findings with well-defined follow-up guidelines. Between January 1, 2012 and December 31, 2014, 7173 patients underwent in-patient abdominal CT without concurrent chest CT; of these patients, 62.2% were ≥60 years old, 50.6% were men, and 45.5% were current or former smokers. Incidental pulmonary nodules were reported in 402 patients (5.6%; 95% confidence interval [CI], 5.1%-6.2%). Based on nodule size, reported size stability, and patients’ smoking status, 208 patients (2.9%; 95% CI, 2.5%-3.3%) required follow-up surveillance, per the 2005 Fleischner Society guidelines. Of these 208 patients, 48 (23%) received discharge summaries that included documentation of the incidental findings, with 34 summaries including a recommendation for nodule follow-up and 19 summaries including a time frame for repeat CT. Three factors were positively associated with the inclusion of the pulmonary nodule in the discharge summary: mention of the pulmonary nodule in the summary headings of the radiology report (P ≤ 0.001), radiologist recommendations for further surveillance (P ≤ 0.001), and medical discharging service (P = 0.016). These findings highlight the need for a multidisciplinary systems-based approach to incidental pulmonary nodule documentation and surveillance. Journal of Hospital Medicine 2017;12:454-457. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Incidental findings create both medical and logistical challenges regarding communication.1,2 Pulmonary nodules are among the most frequent and medically relevant incidental findings, being noted in up to 8.4% of abdominal computed tomography (CT) scans.3 There are guidelines regarding proper follow-up and management of such incidental pulmonary nodules, but appropriate evidence-based surveillance imaging is often not performed, and many patients remain uninformed. Collins et al.4 reported that, before initiation of a standardized protocol, only 17.7% of incidental findings were communicated to patients admitted to the trauma service; after protocol initiation, the rate increased to 32.4%. The hospital discharge summary provides an opportunity to communicate incidental findings to patients and their medical care providers, but Kripalani et al.5 raised questions regarding the current completeness and accuracy of discharge summaries, reporting that 65% of discharge summaries omitted relevant diagnostic testing, and 30% omitted a follow-up plan.
We conducted a study to determine how often incidental pulmonary nodules found on abdominal CT are documented in the discharge summary, and to identify factors associated with pulmonary nodule inclusion.
METHODS
This was a retrospective cohort study of hospitalized patients ≥35 years of age who underwent in-patient abdominal CT between January 1, 2012 and December 31, 2014. Patients were identified by cross-referencing hospital admissions with Current Procedural Terminology (CPT) codes indicating abdominal CT (74176, 74177, 74178, 74160, 74150, 74170). Patients with chest CT (CPT codes 71260, 71250, 71270) during that hospitalization or within 30 days before admission were excluded to ensure that pulmonary nodules were incidental and asymptomatic. The index hospitalization was defined as the first hospitalization during which the patient was diagnosed with an incidental pulmonary nodule on abdominal CT, or the first hospitalization during the study period for patients without pulmonary nodules. All patient charts were manually reviewed, and baseline age, sex, and smoking status data collected.
Radiology reports were electronically screened for the words nodule and nodules and then confirmed through manual review of the full text reports. Nodules described as tiny (without other size description) were assumed to be <4 mm in size, per manual review of a small sample. Nodules were deemed as falling outside the Fleischner Society criteria guidelines (designed for indeterminate pulmonary nodules), and were therefore excluded, if any of seven criteria were met: The nodule was (1) cavitary, (2) associated with a known metastatic disease, (3) associated with a known granulomatous disease, (4) associated with a known inflammatory process, (5) reported likely to represent atelectasis, (6) reported likely to be a lymph node, or (7) previously biopsied.4
For each patient with pulmonary nodules, a personal history of cancer was obtained. Nodule size, characteristics, and stability compared with available prior imaging were recorded. Radiology reports were reviewed to determine if pulmonary nodules were mentioned in the summary headings of the reports or in the body of the reports and whether specific follow-up recommendations were provided. Hospital discharge summaries were reviewed for documentation of pulmonary nodule(s) and follow-up recommendations. Discharging service (medical/medical subspecialty, surgical/surgical subspecialty) was noted, along with the patients’ condition at discharge (alive, alive on hospice, deceased).
The frequency of incidental pulmonary nodules on abdominal CT during hospitalization and the frequency of nodules requiring follow-up were reported using a point estimate and corresponding 95% confidence interval (CI). The χ2 test was used to compare the frequency of pulmonary nodules across patient groups. In addition, for patients found to have incidental nodules requiring follow-up, the χ2 test was used to compare across groups the percentage of patients with discharge documentation of the incidental nodule. In all cases, 2-tailed Ps are reported, with P ≤ 0.05 considered statistically significant.
