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
Our findings highlight other opportunities for quality improvement in IPN management. Almost a quarter of hospitalists reported formally consulting pulmonologists for IPN management. Hospitalist groups wishing to improve value could partner with their radiology departments and embed the Fleischner Society recommendations into their imaging reports to potentially reduce unnecessary pulmonary consultations. Among the 59 hospitalists who agreed that IPN management was challenging, a majority cited the scheduling process (30%) as a barrier. Redesigning the scheduling process for follow-up imaging could be a focus in local efforts to improve IPN management. Strengthening communication between hospitalists and PCPs may provide additional opportunities for improved IPN follow-up, given the centrality of PCPs to ensuring such follow-up. This might include enhancing direct communication between hospitalists and PCPs for high-risk patients, or creating systems to ensure robust indirect communication, such as the implementation of standardized discharge summaries that uniformly include essential follow-up information.
At our institution, given the large volume of high-risk patients and imaging performed, and the available resources, we have established an IPN consult team to improve follow-up for inpatients with IPNs identified by chest CTs on Medicine services. The team includes a nurse practitioner (NP) and a pulmonologist who consult by default, to notify patients of their findings and recommended follow-up, and communicate results to their PCPs. The IPN consult team also sees patients for follow-up in the ambulatory IPN clinic. This initiative has addressed the most frequently cited challenges identified in our nationwide hospitalist survey by taking the communication and follow-up out of the hospitalists’ hands. To ensure identification of all IPNs by the NP, our radiology department has created a structured template for radiology attendings to document follow-up for all chest CTs reviewed based on the Fleischner Society guidelines. Compliance with use of the template by radiologists is followed monthly. After a run-in period, almost 100% of chest CT reports use the structured template, consistent with published findings from similar initiatives,14 and 100% of patients with new IPNs identified on the inpatient Medicine services have had an IPN consult.
The major limitation of our survey study is the response rate. It is difficult to determine in what direction this could bias our results, as those with and without experience in managing IPNs may have been equally likely to complete the survey. Despite the low response rate, our sample targeted the general cohort of conference attendees (rather than specific forums such as audiences interested in quality or imaging), and the descriptive characteristics of our convenience sample align well with the overall conference attendee demographics (eg, conference attendees were 77% hospitalist attendings and 9% advanced practice providers, as compared with 82% and 7% of survey respondents, respectively), suggesting that our respondents were representative of conference attendees as a whole.
Next steps for this work at our institution include developing systems to ensure appropriate follow-up for those with IPNs identified on chest CTs performed for Medicine outpatients. In addition, our institution is collaborating on a national study to compare outcomes resulting from following the traditional Fleischner Society recommendations compared to the new 2017 recommendations, which recommend more lenient follow-up.15
