With advancement in imaging techniques, incidental pulmonary nodules (IPNs) are routinely found on imaging studies. Depending on the size, an IPN has diagnostic uncertainty. Is it a benign finding? Will it progress to cancer? These questions have the potential to create anxiety for our patients. Between 2012 and 2014, 19,739 patients were discharged from hospitals in the United States with a diagnosis of a solitary pulmonary nodule.1 Roughly 7,500 were discharged after an inpatient stay; the remainder from the emergency room. Aggregate costs for these visits totaled $49 million. The exact number of nodules receiving follow-up is unknown.
The Fleischner guidelines, updated in 2017, outline management for IPNs.2 Depending on nodule size and patient risk factors, repeat imaging is either not indicated or one to two follow-up scans could be recommended. In this issue of the Journal of Hospital Medicine®, two reports assess provider awareness of the Fleischner guidelines and examine the proportion of patients receiving follow-up.
Umscheid et al. surveyed hospitalists to understand their approach IPN management. Of 174 respondents, 42% were unfamiliar with the Fleischner guidelines.3 The authors proposed methods for improving provider awareness, including better communication between hospitalists and primary care providers, better documentation, and in the case of their institution, the development of an IPN consult team. The IPN consult team is composed of a nurse practitioner and pulmonologist. They inform primary care providers of patient findings and need for follow-up. If no follow-up is made, the team will see the patients in an IPN ambulatory clinic to ensure follow-up imaging is obtained.
Kwan et al. found that fewer than 50% of patients with high-risk new pulmonary nodules received follow-up.4 Although a single-site study, the study is consistent with prior work on tests pending at discharge, which essentially show that there are poor follow-up rates.5,6 Follow-up was more likely when the IPN was mentioned in the discharge summary. This conclusion builds on previous work showing that IPNs are more likely to be included in a discharge summary if the nodule is noted in the report heading, the radiologist recommends further imaging, and the patient is discharged from a medicine service as opposed to a surgical service.7 IPN follow-up is less likely if results are mentioned in the findings section alone.5
IPN follow-up is a piece of a larger issue of how best to ensure appropriate follow-up of any tests pending after discharge. A systematic review of discharge interventions found improvement in follow-up when discharge summaries are combined with e-mail alerts.6 A study of the effects of integrated electronic health records (EHR) web modules with discharge specific instructions showed an increase in follow-up from 18% to 27%.8 Studies also consider provider-to-patient communication. One intervention uses the patient portal to remind patients to pick up their medications,9 finding a decrease in nonadherence from 65.5% to 22.2%. Engaging patients by way of patient portals and reminders are an effective way to hold both the physician and the patient accountable for follow-up. Mobile technologies studied in the emergency department show patient preferences toward texting to receive medication and appointment reminders.10 Given wide-spread adoption of mobile technologies,11 notification systems could leverage applications or texting modalities to keep patients informed of discharge appointments and follow-up imaging studies. Similar interventions could be designed for IPNs using the Fleischner guidelines, generating alerts when patients have not received follow-up imaging.
The number of IPNs identified in the hospital will likely remain in the tens of thousands. From the hospitalist perspective, the findings presented in this month’s Journal of Hospital Medicine suggest that patients be educated about their findings and recommended follow-up, that follow-up be arranged before discharge, and that findings are clearly documented for patients and primary care providers to review. More study into how to implement these enhancements is needed to guide how we focus educational, systems, and technological interventions. Further study is also needed to help understand the complexities of communication channels between hospitalists and primary care physicians. As hospitalist workflow is more integrated with the EHR and mobile technology, future interventions can facilitate follow-up, keeping all providers and, most importantly, the patient aware of the next steps in care.
Author support is provided by the South Texas Veterans Health Care System. The views expressed are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs.
The authors report no financial conflicts of interest.