Original article
Follow-up of Incidental Pulmonary Nodules and the Radiology Report

https://doi.org/10.1016/j.jacr.2013.08.003Get rights and content

Purpose

Incidental pulmonary nodules that require follow-up are often noted on chest CT. Evidence-based guidelines regarding appropriate follow-up have been published, but the rate of adherence to guideline recommendations is unknown. Furthermore, it is unknown whether the radiology report affects the nodule follow-up rate.

Methods

A review of 1,000 CT pulmonary angiographic studies ordered in the emergency department was performed to determine the presence of an incidental pulmonary nodule. Fleischner Society guidelines were applied to ascertain if follow-up was recommended. Radiology reports were classified on the basis of whether nodules were listed in the findings section only, were noted in the impression section, or had explicit recommendations for follow-up. Whether the rate of nodule follow-up was affected by the radiology report was determined according to these 3 groups.

Results

Incidental pulmonary nodules that required follow-up were noted on 9.9% (95% confidence interval, 8%–12%) of CT pulmonary angiographic studies. Follow-up for nodules was poor overall (29% [28 of 96]; 95% confidence interval, 20%–38%) and decreased significantly when the nodules were mentioned in the findings section only (0% [0 of 12]). Specific instructions to follow up nodules in radiology reports still resulted in a low follow-up rate of 29% (19 of 65; 95% confidence interval, 18%–40%).

Conclusions

Incidental pulmonary nodules detected on CT pulmonary angiography are common and are frequently not followed up appropriately. Although the inclusion of a pulmonary nodule in the impression section of a radiology report is helpful, it does not ensure follow-up. Better systems for appropriate identification and follow-up of incidental findings are needed.

Section snippets

Background

CT pulmonary angiography is ordered frequently in emergency departments (EDs) to evaluate clinically suspected pulmonary embolus [1]. However, incidental pulmonary nodules that require follow-up are often noted on these examinations [2]. The most widely accepted, evidence-based guidelines for follow-up of incidentally noted pulmonary nodules are the Fleischner Society guidelines [3]. These guidelines use pretest probability of malignancy (on the basis of nodule size, patient age, and presence

Methods

A waiver of the requirement for individual written informed consent was received from the institutional review board of Intermountain Healthcare. We identified 3,500 consecutive CT pulmonary angiographic examinations ordered in the EDs of LDS Hospital and Intermountain Medical Center for suspicion of pulmonary embolus between May 2009 and June 2010 and reported on adherence to Prospective Investigation of Pulmonary Embolism Diagnosis II guidelines in ordering these studies in the ED [7]. At the

Results

Table 1 summarizes the baseline characteristics of the 1,000 patients.

Discussion

Incidental pulmonary nodules are commonly identified on CT scans 2, 9. The 9.9% (99 of 1,000; 95% CI, 8%–12%) incidence of incidental pulmonary nodules that required follow-up in our study of CT pulmonary angiographic examinations ordered in the ED is similar to rates found in previous studies that have examined the rate of incidental findings on chest CT [2].

We found that only 29% (28 of 96; 95% CI, 20%–38%) of pulmonary nodules that required follow-up on the basis of Fleischner Society

Conclusions

Incidental pulmonary nodules are common and are often not followed up appropriately. Although inclusion of a pulmonary nodule in the impression section of a radiology report is helpful, it does not ensure follow-up. Even specific instructions to follow up nodules in radiology reports do not improve the follow-up rate. In the face of ever growing clinician information overload and patient care discontinuity, better systems for appropriate identification and follow-up of incidental findings are

Take-Home Points

  • Incidental pulmonary nodules that require follow-up are often noted on chest CT (9.9% [99 of 1,000]; 95% CI, 8%–12%).

  • Even when follow-up recommendations are explicitly stated in the radiology report, follow-up remains poor (29% [19 of 65]; 95% CI, 18%–40%).

  • However, when nodules are noted only in the findings sections of radiology reports, the nodule follow-up rate is significantly lower (0% [0 of 12]).

  • Although our study shows the importance of including findings in the impression section of the

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