National Survey of Hospitalists’ Experiences with Incidental Pulmonary Nodules

We developed a 14-item survey to assess hospitalists’ exposure to and management of IPNs. The survey targeted attendees of the 2016 Society of Hospital Medicine (SHM) annual conference and was available for completion on a tablet at the conference registration desk, the SHM kiosk in the exhibit hall, and at the entrance and exit of the morning plenary sessions. Following the annual conference, the survey was e-mailed to conference attendees, with one follow-up e-mailed to nonresponders.

Analyses were descriptive and included proportions for categorical variables and median and mean values and standard deviations for continuous variables. In addition, we examined the association between survey items and a response of “yes” to the question “Are you familiar with the Fleischner Society guidelines for the management of incidental pulmonary nodules?”

Associations between familiarity with the Fleischner Society guidelines and survey items were examined using Pearson’s chi-square test for categorical variables, Fisher’s exact test for categorical variables with small sample sizes, the Cochran–Armitage test for trend for ordinal variables, and the t-test for continuous variables. The associations between categorical items were measured by odds ratios with 95% confidence intervals. Statistical tests were two-sided using a P =.05 level for statistical significance. All analyses were performed using R version 3.4.4 (R Foundation for Statistical Computing, Vienna, Austria), with the R packages MASS, stats, and Publish. Institutional review board exemption was granted.

We received 174 responses from a total of 3,954 conference attendees. The majority were identified as hospitalist physicians, and most of them were internists (Table 1). About half practiced at a university or a teaching hospital, and more than half supervised trainees and practiced for more than five years. Respondents were involved in direct patient care (whether a teaching or a nonteaching service) for a median of 28 weeks annually (mean 31.2 weeks, standard deviation 13.5), and practice regions were geographically diverse. All respondents reported seeing at least one IPN case in the past six months, with most seeing three or more cases (Table 2). Despite this exposure, 42% were unfamiliar with the Fleischner Society guidelines. When determining the need for IPN follow-up, most of them utilized radiology report recommendations or consulted national or international guidelines, and a third spoke with radiologists directly. About a third agreed that determining the need for follow-up was challenging, with 39% citing patient factors (eg, lack of insurance, poor access to healthcare), and 30% citing scheduling of follow-up imaging. Few reported the availability of an automated tracking system at their institution, although most of them desired automatic notifications of results requiring follow-up.

Unadjusted analyses revealed that supervision of trainees and seeing more IPN cases significantly increased the odds of a survey respondent being familiar with the Fleischner Society guidelines (OR 1.96, 95% CI 1.04-3.68, P =.05, and OR 1.55, 95% CI 1.12-2.18, P =.008, respectively; Supplementary Table 1).

To our knowledge, the survey reported here is the first to examine hospitalists’ knowledge of the Fleischner Society guidelines and their approach to management of IPNs. Although our data suggest that hospitalists are less familiar with the Fleischner Society recommendations than pulmonologists⁸ and radiologists,^8-10 the majority of hospitalists in our study rely on radiology report recommendations to inform follow-up. This suggests that embedding the Fleischner Society recommendations into radiology reports is an effective method to promote adherence to these recommendations, which has been demonstrated in previous research.^11-13 Our study also suggests that hospitalists with more IPN exposure and those who supervise trainees are more likely to be aware of the Fleischner Society recommendations, which is similar to findings from studies examining radiologists and pulmonologists.^8-9