Pulmonary Nodules: What Radiologists Should Recommend

Recently, it was acknowledged that radiologists vary widely in whether they recommend follow ups for pulmonary modules. But this is something that deeply needs examination.

A new study by Brigham and Women’s Hospital, published Sunday in JACR, claims organizations need to reform this.

They remind us that lung cancer is still the deadliest form of the disease in the U.S., and pulmonary nodules are one of the most common reasons for repeat CT exams. Typically, guidelines for radiologists dictate how they should respond in such scenarios, noted specialists with the Boston-based institution. However, Brigham found significant differences in the probability of making a follow-up recommendation among physicians in the same subspecialty division.

“Unwarranted variation for pulmonary nodules could have significant downstream implications on not only frequency of repeat imaging, but overall medical costs and quality of patient care,” Neena Kapoor, MD, the Quality and Patient Safety officer in Brigham and Women’s Department of Radiology, and colleagues wrote February 7. “How to alter radiologist behavior and reduce variation in reporting of follow-up recommendations is a challenging problem that likely requires multiple interventions and stakeholder engagement.”

Logically, the only way to help is to better understand the issue, therefore Kapoor and co-authors analyzed 142,000 chest and abdominal reports, gathered between 2016 to 2018 in its abdominal, thoracic and emergency radiology subspecialty divisions. Kapoor’s team harnessed a natural language processing tool to pinpoint 24,512 reports with pulmonary nodules during that period that ended up being benign.

Altogether, the team found that 4,939 (20%) of reports had a follow-up recommendation for pulmonary nodules. The majority were CT scans of the chest (76%), outpatient studies (63%), and interpreted by thoracic rads (64%). Study authors calculated a 4.3-fold difference between radiologists in the probability of making a follow-up recommendation for a pulmonary nodule.

What are some of the other possible reasons for lack of follow-up? Kapoor et al. also learned that studies for male patients and abdominal CTs were less likely to have a pulmonary nodule follow-up recommendation. On the other side, older patients, the presence of a trainee, inpatient and ED examinations were all associated with higher rates. The authors, however, did not delve into the reasons for these discrepancies. If the sense of urgency leads radiologists to subconsciously push follow ups more often, this needs to be studied and addressed in order to catch early diagnoses of the awfully aggressive disease.

“Our work serves as a first step for future work to quantify the magnitude of variability in follow-up recommendations for pulmonary nodules,” the team concluded. “Further studies will need to determine the downstream implications of variation in follow-up recommendations, including the clinical appropriateness of radiologist recommendations, variability in length of follow-up or imaging modalities used, and downstream imaging costs and quality of care.”