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Lung Nodule Follow-up at an Academic Center: A Revealing Quality Study FREE TO VIEW

Sacha Bhinder; Nabil Abduljalil; Simon Houston; Taryn Simms; Djeven Deva; Kieran McIntyre
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University of Toronto, Toronto, ON, Canada

Chest. 2014;146(4_MeetingAbstracts):557A. doi:10.1378/chest.1959255
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SESSION TITLE: Cost and Quality Improvement

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 28, 2014 at 08:45 AM - 10:00 AM

PURPOSE: Published guidelines provide recommendations for follow-up of lung nodules identified on CT imaging for lung cancer detection. The ACCP has identified overuse of CT scanning for pulmonary nodules as the top priority under the Choosing Wisely campaign. We sought to determine the adherence to this recommendation at an urban, academic hospital.

METHODS: We performed a retrospective chart review using the St. Michael's Hospital (SMH) Radiology image server by searching for “nodule” AND one or more of “follow, recommend, suggest, encourage, advise, or Fleischner” on all CT scans performed between January 1 and June 30, 2012. Charts were surveyed until February 1, 2014 to assess compliance with nodule follow-up. Overall, we identified 852 Chest CT scans, of which 157 scans met inclusion criteria for having 1) no prior CT chest images or reports for comparison and 2) inclusion of specific recommendations for nodule follow-up with a defined time point for a repeat CT. The first fifty sequential inpatients and outpatients and all ER patients with initial CT scans were analyzed for compliance with nodule follow-up at SMH, all University of Toronto affiliated hospitals, and regional community hospitals.

RESULTS: A total of sixty-six charts met inclusion criteria for analysis. Appropriate nodule follow-up was performed for twenty-eight patients (42%). Patients known to a hospital physician that underwent their initial CT scan as an outpatient had a nodule follow-up compliance rate of 63% (22/35) compared to 27% for patients that underwent their initial CT scan while admitted as an inpatient (3/11). Only three of twenty patients (15%) with initial scans in the Emergency Department underwent subsequent nodule follow-up. Eighty-six percent (24/28) of CT scans for nodule follow-up were ordered using low-dose technique.

CONCLUSIONS: Our results demonstrate significant variability in compliance with nodule follow-up recommendations, and that a patient’s admission status at the time of their initial CT scan appears to impact adherence to follow-up recommendations. Emergency Room patients were least likely to have appropriate follow-up of CT detected nodules and this may represent a targeted population for which improvement initiatives can be directed.

CLINICAL IMPLICATIONS: Suboptimal follow-up of pulmonary nodules potentially exposes patients to preventable morbidity and mortality. Establishment of a formal "nodule clinic" may improve follow-up for patients in whom pulmonary nodules are detected and thus reduce potential harm.

DISCLOSURE: The following authors have nothing to disclose: Sacha Bhinder, Nabil Abduljalil, Simon Houston, Taryn Simms, Djeven Deva, Kieran McIntyre

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