The Chain of Adherence for Incidentally Detected Pulmonary Nodules after an Initial Radiologic Imaging Study: A Multisystem Observational Study.

Rationale: Millions of people are diagnosed with incidental pulmonary nodules every year. Although most nodules are benign, it is universally recommended that all patients be assessed to determine appropriate follow-up and ensure that it is obtained. Objectives: To determine the degree of concordance and adherence to 2005 Fleischner Society guidelines among radiologists, clinicians, and patients at two Veterans Affairs healthcare systems with incidental nodule tracking systems. Methods: Trained researchers abstracted data from the electronic health records of patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. We classified radiology reports and patient follow-up into three categories. Radiologist-Fleischner adherence was the agreement between the radiologist's recommendation in the computed tomography (CT) report and the 2005 Fleischner Society guidelines. Clinician/patient-Fleischner concordance was agreement between patient follow-up and the guidelines. Clinician/patient-radiologist adherence was agreement between the radiologist's recommendation and patient follow-up. We evaluated whether the recommendation or follow-up was more (e.g., sooner) or less (e.g., later) aggressive than recommended. Results: After exclusions, 4,586 patients with 7,408 imaging tests (n = 4,586 initial chest CT scans; n = 2,717 follow-up chest CT scans; n = 105 follow-up low-dose CT scans) were included. Among radiology reports that could be classified in terms of Fleischner Society guidelines (n = 3,150), 80% had nonmissing radiologist recommendations. Among those reports, radiologist-Fleischner adherence was 86.6%, with 4.8% more aggressive and 8.6% less aggressive. Among patients whose initial scans could be classified, clinician/patient-Fleischner concordance was 46.0%, 14.5% were more aggressive, and 39.5% were less aggressive. Clinician/patient-radiologist adherence was 54.3%. Veterans whose radiology reports were adherent to Fleischner Society guidelines had a substantially higher proportion of clinician/patient-Fleischner concordance: 52.0% concordance among radiologist-Fleischner adherent versus 11.6% concordance among radiologist-Fleischner nonadherent. Conclusions: In this multi-health system observational study of incidental pulmonary nodule follow-up, we found that radiologist adherence to 2005 Fleischner Society guidelines may be necessary but not sufficient. Our results highlight the many facets of care processes that must occur to achieve guideline-concordant care.

Patient and Clinician Characteristics Associated with Adherence. A Cohort Study of Veterans with Incidental Pulmonary Nodules.

RATIONALE: Many patients are diagnosed with small pulmonary nodules for which professional societies recommend subsequent imaging surveillance. Adherence to these guidelines involves many steps from both clinicians and patients but has not been well studied. OBJECTIVES: In a health care setting with a nodule tracking system, we evaluated the association of communication processes and distress with patient and clinician adherence to recommended follow up and Fleischner Society guidelines, respectively. METHODS: We conducted a prospective, longitudinally assessed, cohort study of patients with incidentally detected nodules who received care at one Veterans Affairs Medical Center. We measured patient-centered communication with the Consultation Care Measure and distress with the Impact of Event Scale. We abstracted data regarding participant adherence to clinician recommendations (defined as receiving the follow-up scan within 30 d of the recommended date) and clinician adherence to Fleischner guidelines (defined as planning the follow-up scan within 30 d of the recommended interval) from the electronic medical record. We measured associations of communication and distress with adherence using multivariable-adjusted generalized estimating equations. MEASUREMENTS AND MAIN RESULTS: Among 138 veterans, 39% were nonadherent at least once during follow up. Clinicians were nonadherent to Fleischner guidelines for 27% of follow-up scans. High-quality communication (adjusted odds ratio, 3.65; P = 0.02) and distress (adjusted odds ratio, 0.38; P = 0.02) were associated with increased and decreased participant adherence, respectively. Neither was associated with clinician adherence. CONCLUSIONS: Patients and clinicians often do not adhere to nodule follow-up recommendations. Interventions designed to improve communication quality and decrease distress may also improve patient adherence to nodule follow-up recommendations.

Serum progesterone testing to predict ectopic pregnancy in symptomatic first-trimester patients.

STUDY OBJECTIVE: This study was conducted to prospectively measure the accuracy of serum progesterone levels to detect ectopic pregnancy. METHODS: Seven hundred sixteen symptomatic first-trimester emergency department patients with abdominal pain or vaginal bleeding at a tertiary care military teaching hospital had progesterone levels measured by radioimmunoassay with results unavailable to the treating physician. All patients were monitored until a criterion standard diagnosis of intrauterine pregnancy or ectopic pregnancy was confirmed. RESULTS: A 14-month derivation phase (n=399) used receiver operating characteristic curve testing to select a cutoff value of progesterone less than 22 ng/mL. A 12-month validation phase (n=317) then retested this cutoff value. Combining both phases, there were 434 (61%) viable intrauterine pregnancies, 229 (32%) nonviable intrauterine pregnancies, and 52 (7. 3%) ectopic pregnancies, of which 17 were ruptured. Sensitivity, specificity, positive predictive values, and negative predictive values (95% confidence intervals) for progesterone levels less than 22 ng/mL to detect ectopic pregnancy were 100% (94% to 100%), 27% (23% to 30%), 10% (7% to 12%), and 100% (98% to 100%), respectively. CONCLUSION: Given similar disease prevalence, roughly one fourth (178/716) of symptomatic patients can be classified as low risk (0%, 95% confidence interval 0 to 2%) for having an ectopic pregnancy using a progesterone cutoff of 22 ng/mL. Whether implementation of rapid progesterone testing can safely expedite care and reduce the need for urgent diagnostic evaluation or admission remains to be determined.