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2017 HSR&D/QUERI National Conference Abstract

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4062 — Targeting Incomplete and Inappropriate Recommendations by Radiologists as a Quality Improvement Initiative

Lead/Presenter: Laura Feemster, COIN - Seattle/Denver
All Authors: Takasugi JE (VA Puget Sound Health Care System) Feemster LC (Seattle/Denver COIN) Helfrich CD (Seattle/Denver COIN) Todd K (Seattle/Denver COIN) Au DH (Seattle/Denver COIN) Zeliadt SB (Seattle/Denver COIN)

Objectives:
Following small lung nodules inappropriately is potentially harmful because it puts patients at risk of unnecessary invasive procedures, causes anxiety resulting from prolonged surveillance, wastes clinical resources, and leads to unnecessary radiation exposure from repeated tests. Recent guidelines, including recommendations from Choosing Wisely, have emphasized that small and stable lung nodules should not be routinely followed.

Methods:
As part of a quality improvement initiative, we reviewed radiology reports of 153 cancer-free patients identified in 2011 with pulmonary findings or lung nodules on CT imaging. Findings were grouped into three categories based on Fleischner Society guidelines: 1) very small (=< 4mm); 2) benign/stable; and 3) indeterminate requiring additional surveillance. An expert radiologist reviewed recommendations and clinical indications included in the text report classifying follow-up recommendations as appropriate, inappropriate or incomplete.

Results:
Our review focusing on 139 (91%) patients with small and stable nodules found that only 47% of very small nodules or clearly benign or stable nodules (categories 1 and 2) received an appropriate recommendation from the radiologist in the CT report. A total of 9% had an inappropriate follow-up recommendation, usually for non-guideline repeat imaging in 6 months. The remaining 43% had incomplete or vague follow-up recommendations. Among the 14 (9%) of patients with indeterminate nodules (category 3), 43% had an appropriate follow-up recommendation included in the text report, with an additional 43% receiving an incorrect recommendation with the follow-up interval not appropriately specified, and 14% had incomplete recommendations.

Implications:
There are major gaps in quality of radiology reports related to the follow-up of small and stable pulmonary nodules. These baseline data highlight the need for targeting radiologists' reports as a critical first step in reducing inappropriate and unnecessary follow-up.

Impacts:
VHA performs over 200,000 diagnostic chest CTs annually, with as many as 1/3rd identified with a small or benign pulmonary nodule that may not need repeat follow-up. Ensuring these Veterans do not receive unnecessary or harmful care is critical. We are conducting a QUERI-funded local quality improvement initiative working with radiologists to improve the quality and completeness of recommendations and ensure they are consistent with professional guidelines.